Healthy families: study protocol for a randomized controlled trial of a screening, brief intervention, and referral to treatment intervention for caregivers to reduce secondhand smoke exposure among pediatric emergency patients

Inflammatory marker levels in children with tobacco smoke exposure

BACKGROUND

Tobacco smoke exposure (TSE) has inflammatory and immunosuppressive effects which may be associated with altered levels of inflammatory markers and pediatric illnesses.

OBJECTIVE

The primary objective was to examine the associations of cotinine-confirmed and parent-reported child TSE patterns and discharge diagnoses with C-reactive protein (CRP), IL-8, and IL-10 in 0-11-year-old pediatric emergency department (PED) patients who lived with ≥ 1 smoker.

METHODS

Saliva samples were obtained from 115 children with a mean (SD) age of 3.5 (3.1) years during the PED visit (T0). Saliva was analyzed for cotinine, CRP, IL-8, and IL-10. Parents self-reported their children's TSE patterns; children's medical records were reviewed to identify and categorize discharge diagnoses. Linear regression models were utilized to find T0 associations of cotinine-confirmed and parent-reported child TSE patterns, and PED diagnoses with each inflammatory marker. All models were adjusted for child race/ethnicity, child sex, annual household income, and housing type. The TSE models also adjusted for child discharge diagnosis.

RESULTS

At T0, the geometric mean (GeoM) of cotinine was 4.1 ng/ml [95 %CI = 3.2-5.2]; the GeoMs of CRP, IL-8, and IL-10 were 3,326 pg/ml [95 %CI = 2,696-4,105], 474 pg/ml [95 %CI = 386-583], and 1.1 pg/ml [95 %CI = 0.9-1.3], respectively. Parent-reported child TSE patterns were positively associated with ln-transformed CRP levels, while adjusting for the covariates (β^ = 0.012 [95 %CI:0.004-0.020], p = 0.037). In the parent-reported child TSE pattern model, there were significant positive associations between the covariate of child age with CRP and IL-8 levels (p = 0.028 and p < 0.001, respectively). Children with a bacterial diagnosis had higher IL-8 levels (p = 0.002) compared to the other diagnosis groups.

CONCLUSIONS

Results indicate that parent-reported child TSE increases the expression of CRP in ill children and supports prior work demonstrating that IL-8 is higher in children with TSE who have bacterial infections. These findings should be examined in future research with ill children with and without TSE.

Contamination of surfaces in children's homes with nicotine and the potent carcinogenic tobacco-specific nitrosamine NNK

BACKGROUND

Tobacco smoke exposure (TSE) through secondhand and thirdhand smoke is a modifiable risk factor that contributes to childhood morbidity. Limited research has assessed surface TSE pollution in children's environments as a potential source of thirdhand smoke exposure, and none have examined levels of the tobacco-specific nitrosamine 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK) on surfaces.

OBJECTIVE

This study measured surface NNK and nicotine in children's homes and associations with sociodemographics and parent-reported TSE behaviors. We assessed correlations of surface NNK and nicotine with dust NNK, dust nicotine, and child cotinine.

METHODS

Home surface wipe NNK and nicotine data from 84 children who lived with smokers were analyzed. Tobit and simple linear regression analyses were conducted to assess associations of surface NNK and nicotine with child characteristics. Spearman's (ρ) correlations assessed the strength of associations between environmental markers and child cotinine.

RESULTS

Nearly half (48.8%) of children's home surfaces had detectable NNK and 100% had detectable nicotine. The respective geometric means (GMs) of surface NNK and nicotine loadings were 14.0 ng/m2 and 16.4 µg/m2. Surface NNK positively correlated with surface nicotine (ρ = 0.54, p < 0.001) and dust NNK (ρ = 0.30, p = 0.020). Surface nicotine positively correlated with dust NNK (ρ = 0.42, p < 0.001) and dust nicotine (ρ = 0.24, p = 0.041). Children with household incomes ≤$15,000 had higher surface NNK levels (GM = 18.7 ng/m2, p = 0.017) compared to children with household incomes >$15,000 (GM = 7.1 ng/m2). Children with no home smoking bans had higher surface NNK (GM = 18.1 ng/m2, p = 0.020) and surface nicotine (GM = 17.7 µg/m2, p = 0.019) levels compared to children with smoking bans (GM = 7.5 ng/m2, 4.8 µg/m2, respectively).

IMPACT

Although nicotine on surfaces is an established marker of thirdhand smoke pollution, other thirdhand smoke contaminants have not been measured on surfaces in the homes of children living with smokers. We provide evidence that the potent carcinogenic tobacco-specific nitrosamine NNK was detectable on surfaces in nearly half of children's homes, and nicotine was detectable on all surfaces. Surface NNK was positively correlated with surface nicotine and dust NNK. Detectable surface NNK levels were found in homes with indoor smoking bans, indicating the role of NNK as a persistent thirdhand smoke pollutant accumulating on surfaces as well as in dust.

Changes and stability of hand nicotine levels in children of smokers: Associations with urinary biomarkers, reported child tobacco smoke exposure, and home smoking bans

BACKGROUND

Exposure to thirdhand smoke (THS) residue takes place through inhalation, ingestion, and dermal transfer. Hand nicotine levels have been proposed to measure THS pollution in the environment of children, but little is known about its variability and stability over time and correlates of change.

OBJECTIVES

The goal was to determine the stability of hand nicotine in comparison to urinary biomarkers and to explore factors that influence changes in hand nicotine.

METHODS

Data were collected from 0 to 11-year-old children (Mean age = 5.9) who lived with ≥1 tobacco smokers (N = 129). At a 6-week interval, we collected repeated measures of hand nicotine, four urinary biomarkers (cotinine, trans-3'-hydroxycotinine, nicotelline N-oxides, and 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol), and parent-reported child tobacco smoke exposure (TSE). Dependent sample t-tests, correlations, and multivariable regression analyses were conducted to examine the changes in child TSE.

RESULTS

Hand nicotine levels (r = 0.63, p < 0.001) showed similar correlations between repeated measures to urinary biomarkers (r = 0.58-0.71; p < 0.001). Different from urinary biomarkers, mean hand nicotine levels increased over time (t(113) = 3.37, p < 0.001) being significantly higher in children from homes without smoking bans at Time 2 (p = 0.016) compared to Time 1 (p = 0.003). Changes in hand nicotine correlated with changes in cotinine and trans-3'-hydroxycotinine (r = 0.30 and r = 0.19, respectively, p < 0.05). Children with home smoking bans at Time 1 and 2 showed significantly lower hand nicotine levels compared to children without home smoking bans.

DISCUSSION

Findings indicate that hand nicotine levels provide additional insights into children's exposure to tobacco smoke pollutants than reported child TSE and urinary biomarkers. Changes in hand nicotine levels show that consistent home smoking bans in homes of children of smokers can lower THS exposure. Hand nicotine levels may be influenced by the environmental settings in which they are collected.

"I Don't Want My Child to Be a Guinea Pig": Reasons for Non-Participation in a Parental Tobacco Cessation Trial in the Pediatric Emergency Department Setting

(1) Background: Pediatric emergency department (PED) settings are opportune venues in which to recruit parental smokers into tobacco cessation interventions. However, the barriers associated with parents' participation in PED-based cessation trials are unknown. The objective was to explore parents' reasons for non-participation in a PED-based tobacco cessation trial. (2) Methods: We employed the framework method and conducted a qualitative data analysis of parental smokers who were eligible to participate in a PED-based tobacco cessation trial and did not choose to participate (n = 371). (3) Results: Two main themes emerged about reasons for non-participation: (a) Not interested in participating in a research study, and (b) concerns specific to the study. Parents had various reasons for not participating in the cessation trial including not being interested in quitting, parents' health and well-being, parents' beliefs about research, and time required for the study and follow-up visits. (4) Conclusion: General disinterest and specific study-related concerns were touted as reasons for non-participation in a PED-based tobacco cessation trial. Given the potential reductions in tobacco-related morbidity to both parents and children that tobacco control interventions can facilitate, future tobacco interventions should consider alterations in study design and recruitment strategies to encourage all eligible parental smokers to participate.

The Associations of Trans-3'-Hydroxy Cotinine, Cotinine, and the Nicotine Metabolite Ratio in Pediatric Patients with Tobacco Smoke Exposure

(1) Background: Trans-3'-hydroxy cotinine (3HC) and cotinine (COT) are tobacco smoke exposure (TSE) biomarkers and the 3HC/COT ratio is a marker of CYP2A6 activity, an enzyme which metabolizes nicotine. The primary objective was to assess the associations of these TSE biomarkers with sociodemographics and TSE patterns in children who lived with ≥1 smoker. (2) Methods: A convenience sample of 288 children (mean age (SD) = 6.42 (4.8) years) was recruited. Multiple linear regression models were built to assess associations of sociodemographics and TSE patterns with urinary biomarker response variables: (1) 3HC, (2) COT, (3) 3HC+COT sum, and (4) 3HC/COT ratio. (3) Results: All children had detectable 3HC (Geometric Mean [GeoM] = 32.03 ng/mL, 95%CI = 26.97, 38.04) and COT (GeoM = 10.24 ng/mL, 95%CI = 8.82, 11.89). Children with higher cumulative TSE had higher 3HC and COT (β^ = 0.03, 95%CI = 0.01, 0.06, p = 0.015 and β^ = 0.03, 95%CI = 0.01, 0.05, p = 0.013, respectively). Highest 3HC+COT sum levels were in children who were Black (β^ = 0.60, 95%CI = 0.04, 1.17, p = 0.039) and who had higher cumulative TSE (β^ = 0.03, 95%CI = 0.01, 0.06, p = 0.015). Lowest 3HC/COT ratios were in children who were Black (β^ = -0.42, 95%CI = -0.78, -0.07, p = 0.021) and female (β^ = -0.32, 95%CI = -0.62, -0.01, p = 0.044). (4) Conclusion: Results indicate that there are racial and age-related differences in TSE, most likely due to slower nicotine metabolism in non-Hispanic Black children and in younger children.

Carcinogenic and tobacco smoke-derived particulate matter biomarker uptake and associated healthcare patterns among children

BACKGROUND

The objective was to assess the associations of child tobacco smoke exposure (TSE) biomarkers (urinary cotinine, NNAL, and nicotelline N-oxides) and parent-reported smoking and child TSE patterns with total hospital visits, pediatric emergency department (PED) visits, urgent care (UC), revisits, and hospital admissions among 0-9-year-olds.

METHODS

A convenience sample of PED/UC patients (N = 242) who presented to a large, US children's hospital who had baseline urine samples assayed for the TSE biomarkers of interest were included. Biomarker levels were log-transformed, and linear and Poisson regression models were built.

RESULTS

The geometric means of child cotinine, creatinine-adjusted NNAL, and N-oxide levels were 11.2 ng/ml, 30.9 pg/mg creatinine, and 24.1 pg/ml, respectively. The mean (SD) number of daily cigarettes smoked by parents was 10.2 (6.1) cigarettes. Each one-unit increase in log-NNAL levels was associated with an increase in total UC visits (aRR = 1.68, 95% CI = 1.18-2.39) among 0-9-year-olds, while controlling for the covariates. Each one-unit increase in child log-NNAL/cotinine ratio (×103) values was associated with an increase in total hospital visits (aRR = 1.39, 95% CI = 1.10-1.75) and UC visits (aRR = 1.56, 95% CI = 1.14-2.13) over 6 months.

CONCLUSION

Systematic screening for child TSE should be conducted during all hospital visits. The comprehensive assessment of TSE biomarkers should be considered to objectively measure young children's exposure.

IMPACT

Higher levels of cotinine, a widely used tobacco smoke exposure biomarker, have been associated with higher healthcare utilization patterns among children. Less is known on the associations of carcinogenic and tobacco smoke-derived particulate matter biomarker uptake with child healthcare utilization patterns. This study assessed the associations of several biomarkers with healthcare utilization patterns among pediatric emergency department patients ages 0-9 years who lived with tobacco smokers. Higher urinary NNAL biomarker levels, in individual and ratio form with cotinine, increased children's risk for urgent care visits over 6 months. Higher parent-reported cumulative child tobacco smoke exposure increased children's risk for hospital admissions.

Hand nicotine as an independent marker of thirdhand smoke pollution in children's environments

BACKGROUND

Hand nicotine (HN) levels measure children's exposure to tobacco smoke pollutants from thirdhand and secondhand smoke. HN is associated with urinary and salivary cotinine, but the associations of HN with other tobacco smoke exposure (TSE) markers remain unknown.

OBJECTIVES

We compared levels of HN and four urinary TSE biomarkers: cotinine, trans-3'-hydroxycotinine (3HC), nicotelline N-oxides, and 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL), and children's sociodemographic and TSE patterns. We also examined if HN is a plausible pathway for children's exposure to active smoking.

METHODS

Data were collected from 175 non-smoking patients (Mean (SD) age = 5.4 (3.4) years) who lived with ≥1 cigarette smoker(s). HN and TSE biomarker levels were determined using LC-MS/MS. Multivariate and multivariable regression analyses were conducted to examine associations between TSE markers and parent-reported measures, controlling for sociodemographics.

RESULTS

Of the five markers of TSE, cotinine (R² = 0.221; p = 0.003) and HN (R² = 0.247; p = 0.001) showed the strongest overall associations. Of the five markers, only cotinine showed significantly higher levels among Black children (β^=0.307,p<0.05) independent of age, reported exposure, and home smoking bans. Cotinine (β^=0.010,p<0.05), NNAL (β^=0.012,p<0.05), and HN (β^=0.011,p<0.05) showed significant positive associations with reported exposure independent of race, age, and home smoking bans. NNAL (β^=-0.285,p<0.05) and HN (β^=-0.336,p<0.05), but not cotinine, 3HC, and N-oxides, showed significantly lower levels among children who lived in homes with smoking bans. Child age, hand surface area, home smoking ban, and reported exposure independently accounted for 21 % of the variance in HN levels (p = 0.002). HN accounted for 30 % of the variance in cotinine independent of child race and child age.

DISCUSSION

HN levels were associated with modifiable tobacco-related behaviors and shows promise as a marker of sources of THS pollution in a child's environment not captured by measurement of urinary cotinine alone. HN levels provide additional information about TSE, complementing other biomarkers when assessing children's overall TSE.

Comparison of Levels of Three Tobacco Smoke Exposure Biomarkers in Children of Smokers

Objectives: Cotinine, 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL), and N-oxides are biomarkers of tobacco smoke exposure (TSE) used to assess short- and longer-term TSE. The objective of this study was to assess the associations between these TSE biomarkers, sociodemographics, parental smoking, and child TSE patterns among 0–17-year-olds. Methods: A convenience sample of 179 pediatric patients (mean (SD) age = 7.9 (4.3) years) who lived with ≥1 smoker and who had parental assessments completed and urine samples analyzed for the three TSE biomarkers of interest were included. Biomarker levels were log-transformed, univariate regression models were built and Pearson correlations were assessed. Results: In total, 100% of children had detectable levels of cotinine and >96% had detectable NNAL and N-oxide levels. The geometric means of cotinine, NNAL, and N-oxide levels were 10.1 ng/mL, 25.3 pg/mL, and 22.9 pg/mL, respectively. The mean (SD) number of daily cigarettes smoked by parents was 10.6 (6.0) cigarettes. Child age negatively correlated with urinary cotinine (r = −0.202, p = 0.007) and log NNAL levels (r = −0.275, p < 0.001). The highest log-cotinine levels were in children who were younger, of African American race, and whose parents had a lower education, an annual income ≤USD15,000, and no smoking bans. The highest log-NNAL and N-oxide levels were in children whose parents had a lower education, had no smoking bans, and were around higher numbers of cigarettes. Conclusion: Children of smokers who were younger, African American, and had no smoking bans had the highest TSE biomarker levels. Targeted interventions are needed to reduce TSE levels among high-risk children.

Differential associations of hand nicotine and urinary cotinine with children's exposure to tobacco smoke and clinical outcomes

BACKGROUND

Children's overall tobacco smoke exposure (TSE) consists of both inhalation of secondhand smoke (SHS) and ingestion, dermal uptake, and inhalation of thirdhand smoke (THS) residue from dust and surfaces in their environments.

OBJECTIVES

Our objective was to compare the different roles of urinary cotinine as a biomarker of recent overall TSE and hand nicotine as a marker of children's contact with nicotine pollution in their environments. We explored the differential associations of these markers with sociodemographics, parental smoking, child TSE, and clinical diagnoses.

METHODS

Data were collected from 276 pediatric emergency department patients (Median age = 4.0 years) who lived with a cigarette smoker. Children's hand nicotine and urinary cotinine levels were determined using LC-MS/MS. Parents reported tobacco use and child TSE. Medical records were reviewed to assess discharge diagnoses.

RESULTS

All children had detectable hand nicotine (GeoM = 89.7ng/wipe; 95 % CI = [78.9; 102.0]) and detectable urinary cotinine (GeoM = 10.4 ng/ml; 95%CI = [8.5; 12.6]). Although hand nicotine and urinary cotinine were highly correlated (r = 0.62, p < 0.001), urinary cotinine geometric means differed between racial groups and were higher for children with lower family income (p < 0.05), unlike hand nicotine. Independent of urinary cotinine, age, race, and ethnicity, children with higher hand nicotine levels were at increased risk to have discharge diagnoses of viral/other infectious illness (aOR = 7.49; 95%CI = [2.06; 27.24], p = 0.002), pulmonary illness (aOR = 6.56; 95%CI = [1.76; 24.43], p = 0.005), and bacterial infection (aOR = 5.45; 95%CI = [1.50; 19.85], p = 0.03). In contrast, urinary cotinine levels showed no associations with diagnosis independent of child hand nicotine levels and demographics.

DISCUSSION

The distinct associations of hand nicotine and urinary cotinine suggest the two markers reflect different exposure profiles that contribute differentially to pediatric illness. Because THS in a child's environment directly contributes to hand nicotine, additional studies of children of smokers and nonsmokers are warranted to determine the role of hand nicotine as a marker of THS exposure and its potential role in the development of tobacco-related pediatric illnesses.

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

PURPOSE

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

DESIGN

Cross-sectional study of PED children.

SETTING

The PED of a children's hospital.

SAMPLE

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

MEASURES

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

ANALYSIS

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

RESULTS

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

CONCLUSION

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

Hand Nicotine and Cotinine In Children Exposed to Cigars: A Pilot Study

Objectives

Past research has not examined secondhand and thirdhand smoke (THS) exposure in children of cigar smokers. We examined hand nicotine and cotinine levels in children of cigar smokers to explore the contribution of cigar smoke to tobacco smoke exposure (TSE).

Methods

Participants were children (N = 24; mean (SD) age = 6.5 (3.6) years) whose parents smoked cigars only or poly-used cigars and/or cigarettes. Primary outcomes were hand nicotine and urinary cotinine levels.

Results

All children had detectable hand nicotine (range: 7.6-312.5ng/wipe) and cotinine (range: 0.3-100.3ng/ml). Positive correlations were found between hand nicotine and cotinine (r = 0.693, p = .001), hand nicotine and parents who also smoked cigarettes (r = 0.407, p = .048), and hand nicotine and number of smokers around the child (r = 0.436, p = .03). Hand nicotine (r = -0.464, p = .02), but not cotinine (r = -0.266, p = .26), was negatively correlated with child age. Multiple regression results indicated a positive association between hand nicotine and cotinine (p = .002; semi-partial r² = 0.415), irrespective of child age.

Conclusions

The significant association of hand nicotine with urinary cotinine suggests that THS pollution should be assessed in evaluating children's overall TSE to cigars and other tobacco products, and hand nicotine may be a proxy for overall TSE. Younger children may have increased THS pollutant uptake.

Electronic Cigarettes and Their Impact on Allergic Respiratory Diseases: A Work Group Report of the AAAAI Environmental Exposures and Respiratory Health Committee

The explosive rise in popularity of electronic cigarette (e-cig) devices over the past decade has led to controversies over the role of these devices in smoking cessation and harm reduction from combustible cigarette smoking. Increased recognition of potential direct harms of e-cigs, including life-threatening and fatal cases of e-cig and vaping product use-associated lung injury, has emphasized the need to curb use until safety can be established. Of particular concern is the steep rise in e-cig use among teenagers and young adults who have never smoked and among individuals with underlying lung disease, such as asthma. In this report, we describe the different types of e-cig devices available, summarize the available data on the potential health benefits and detriments of e-cig use, and highlight the findings of studies examining e-cigs as smoking cessation tools. Because e-cigs have only gained popularity in the last few years, very few studies have been able to demonstrate an impact of e-cig use on harm reduction related to combustible cigarettes. Moreover, the health effects of e-cigs at a population level must be balanced against the harms of e-cig use, which include nicotine dependence and promoting initiation of cigarette use amongst "never smokers." With respect to smoking cessation, e-cigs appear to serve as switching products that may help individuals reduce or quit cigarette use, but do not address nicotine addiction. Finally, we discuss our recommendations for ways that health care providers can screen and counsel patients on e-cig use. The goal of this report is to provide health care providers with the most recent information on this topic so that they can educate patients on the potential pros and cons of e-cig use.

Healthcare resources attributable to child tobacco smoke exposure

Background

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

Methods and findings

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

Conclusions

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

High Cotinine and Healthcare Utilization Disparities Among Low-Income Children

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

Child tobacco smoke exposure and healthcare resource utilization patterns

BACKGROUND

The objective was to examine the relationship between healthcare resource utilization patterns in tobacco smoke-exposed children (TSE group) compared with unexposed children (non-TSE group).

METHODS

We matched 380 children in the TSE group with 1140 children in the non-TSE group based on child age, sex, race, and ethnicity using propensity scores. Healthcare resource utilization variables included respiratory-related procedures, diagnostic testing, disposition, and medications. Logistic and linear regression models were built.

RESULTS

Child mean age was 4.9 (SD = 0.1) years, 50.5% were female, 55.5% black, and 73.2% had public insurance/self-pay. Compared to the non-TSE group, the TSE group was at increased odds to have the following performed/obtained: nasal bulb suctioning, infectious diagnostic tests, laboratory tests, and radiologic tests. The TSE group was more likely to be admitted to the hospital, and more likely to receive steroids and intravenous fluids during their visit. Among asthmatics, the TSE group was more likely to receive steroids, albuterol, or ipratropium alone, or a combination of all three medications during their visit, and be prescribed albuterol alone or steroids and albuterol.

CONCLUSION

Tobacco smoke-exposed children are more likely to have higher resource utilization patterns, highlighting the importance of screening and providing TSE prevention and remediation interventions.

IMPACT

Tobacco smoke exposure may affect the healthcare resource utilization patterns of children. Evidence is lacking concerning these associations among the highly vulnerable pediatric emergency department patient population. This study examined the association between tobacco smoke exposure and healthcare resource utilization patterns among pediatric emergency department patients. Tobacco smoke exposure increased the risk of pediatric patients having respiratory-related procedures, respiratory-related and non-respiratory-related testing, medications administered during the pediatric emergency department visit, and medications prescribed for home administration. Tobacco smoke-exposed patients were more likely to be admitted to the hospital compared to unexposed patients.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

DISCUSSION

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

TRIAL REGISTRATION

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