Hospital admissions for childhood asthma after smoke-free legislation in England

Protecting Young Lives: A Systematic Review of the Impact of Secondhand Smoke Exposure and Legislative Measures on Children's Health

Each year, a substantial number of global deaths are attributed to secondhand smoke (SHS) exposure, with children representing a significant proportion of these fatalities. This systematic review evaluates the effects of passive smoking, or SHS, on children's health outcomes, focusing on respiratory conditions, behavioral issues, cognitive impairment, growth retardation, and immune system effects. A comprehensive literature search was conducted from July 5 to July 18, 2024, across multiple databases according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. Following the set inclusion and exclusion guidelines, 12 studies were chosen for the review, and their quality was measured using the Newcastle-Ottawa Scale. The findings indicate a strong association between SHS exposure and adverse health outcomes in children, including increased rates of asthma, low birth weight, and behavioral problems. Additionally, smoke-free legislation appears to mitigate some of these harmful effects, though results vary across different regions and populations. The review underscores the urgent need for effective smoking cessation strategies and improved healthcare communication to protect children from the dangers of passive smoking.

Tobacco control policies and respiratory conditions among children presenting in primary care

Tobacco control policies can protect child health. We hypothesised that the parallel introduction in 2008 of smoke-free restaurants and bars in the Netherlands, a tobacco tax increase and mass media campaign, would be associated with decreases in childhood wheezing/asthma, respiratory tract infections (RTIs), and otitis media with effusion (OME) presenting in primary care. We conducted an interrupted time series study using electronic medical records from the Dutch Integrated Primary Care Information database (2000-2016). We estimated step and slope changes in the incidence of each outcome with negative binomial regression analyses, adjusting for underlying time-trends, seasonality, age, sex, electronic medical record system, urbanisation, and social deprivation. Analysing 1,295,124 person-years among children aged 0-12 years, we found positive step changes immediately after the policies (incidence rate ratio (IRR): 1.07, 95% CI: 1.01-1.14 for wheezing/asthma; IRR: 1.16, 95% CI: 1.13-1.19 for RTIs; and IRR: 1.24, 95% CI: 1.14-1.36 for OME). These were followed by slope decreases for wheezing/asthma (IRR: 0.95/year, 95% CI: 0.93-0.97) and RTIs (IRR: 0.97/year, 95% CI: 0.96-0.98), but a slope increase in OME (IRR: 1.05/year, 95% CI: 1.01-1.09). We found no clear evidence of benefit of changes in tobacco control policies in the Netherlands for the outcomes of interest. Our findings need to be interpreted with caution due to substantial uncertainty in the pre-legislation outcome trends.

Impacts of Smoking Ban Policies on Billiard Hall Sales in South Korea Using Objective Sales Information of a Credit Card Company: Quasi-Experimental Study

BACKGROUND

Smoking ban policies (SBPs) are potent health interventions and offer the potential to influence antismoking behavior. The Korean government completely prohibited smoking in indoor sports facilities, including billiard halls, since the government revised the National Health Promotion Act in December 2017.

OBJECTIVE

This study aimed to examine the impact of the SBP on the economic outcomes of indoor sports facilities, particularly billiard halls.

METHODS

This study used credit card sales data from the largest card company in South Korea. Data are from January 2017 to December 2018. Monthly sales data were examined across 23 administrative neighborhoods in Seoul, the capital city of South Korea. We conducted the interrupted time series model using the fixed effects model and the linear regression with panel-corrected standard errors (PCSE).

RESULTS

The sales and transactions of billiard halls were not significantly changed after the introduction of the SBP in the full PCSE models. The R2 of the full PCSE model was 0.967 for sales and 0.981 for transactions.

CONCLUSIONS

The introduction of the SBP did not result in substantial economic gains or losses in the sales of billiard halls. In addition to existing price-based policies, the enhanced SBP in public-use facilities, such as billiard halls, can have a positive synergistic effect on reducing smoking prevalence and preventing secondhand smoke. Health policy makers can actively expand the application of SBPs and make an effort to enhance social awareness regarding the necessity and benefits of public SBPs for both smokers and the owners of hospitality facilities.

Recent trends in asthma diagnosis, preschool wheeze diagnosis and asthma exacerbations in English children and adolescents: a SABINA Jr study

BACKGROUND

Asthma-related burden remains poorly characterised in children in the UK. We quantified recent trends in asthma prevalence and burden in a UK population-based cohort (1‒17-year-olds).

METHODS

The Clinical Practice Research Datalink Aurum database (2008‒2018) was used to assess annual asthma incidence and prevalence in 1‒17-year-olds and preschool wheeze in 1‒5-year-olds, stratified by sex and age. During the same period, annual asthma exacerbation rates were assessed in those with either a diagnosis of preschool wheeze or asthma.

RESULTS

Annual asthma incidence rates decreased by 51% from 1403.4 (95% CI 1383.7 to 1423.2) in 2008 to 688.0 (95% CI 676.3 to 699.9) per 105 person-years (PYs) in 2018, with the most pronounced decrease observed in 1‒5-year olds (decreasing by 65%, from 2556.9 (95% CI 2509.8 to 2604.7) to 892.3 (95% CI 866.9 to 918.3) per 105 PYs). The corresponding decreases for the 6‒11- and 12‒17-year-olds were 36% (1139.9 (95% CI 1110.6 to 1169.7) to 739.9 (95% CI 720.5 to 759.8)) and 20% (572.3 (95% CI 550.4 to 594.9) to 459.5 (95% CI 442.9 to 476.4)) per 105 PYs, respectively. The incidence of preschool wheeze decreased over time and was slightly more pronounced in the 1‒3 year-olds than in the 4-year-olds. Prevalence of asthma and preschool wheeze also decreased over time, from 18.0% overall in 2008 to 10.2% in 2018 for asthma. Exacerbation rates increased over time from 1.33 (95% CI 1.31 to 1.35) per 10 PYs in 2008 to 1.81 (95% CI 1.78 to 1.83) per 10 PYs in 2018.

CONCLUSION

Paediatric asthma incidence decreased in the UK since 2008, particularly in 1-5-year-olds; this was accompanied by a decline in asthma prevalence. Preschool wheeze incidence also decreased in this age group. However, exacerbation rates have been increasing.

Evaluation of Population-Level Tobacco Control Interventions and Health Outcomes: A Systematic Review and Meta-Analysis

Importance

Smoking causes considerable noncommunicable diseases, perinatal morbidity, and mortality.

Objective

To investigate the associations of population-level tobacco-control policies with health outcomes.

Data Sources

PubMed, EMBASE, Web of Science, Cumulated Index to Nursing and Allied Health Literature, and EconLit were searched from inception to March 2021 (updated on 1 March 2022). References were manually searched.

Study Selection

Studies reporting on associations of population-level tobacco control policies with health-related outcomes were included. Data were analyzed from May to July 2022.

Data Extraction and Synthesis

Data were extracted by 1 investigator and cross-checked by a second investigator. Analyses were conducted using the Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guideline.

Main Outcomes and Measures

The primary outcomes were respiratory system disease (RSD), cardiovascular disease (CVD), cancer, mortality, hospitalization, and health care utilization. The secondary outcomes were adverse birth outcomes, such as low birth weight and preterm birth. Random-effects meta-analysis was used to estimate pooled odds ratios (ORs) and 95% CIs.

Results

Of 4952 records identified, 144 population-level studies were included in the final analysis; 126 studies (87.5%) were of high or moderate quality. The most frequently reported policies were smoke-free legislation (126 studies), followed by tax or price increases (14 studies), multicomponent tobacco control programs (12 studies), and a minimum cigarette purchase age law (1 study). Smoke-free legislation was associated with decreased risk of all CVD events (OR, 0.90; 95% CI, 0.86-0.94), RSD events (OR, 0.83; 95% CI, 0.72-0.96), hospitalization due to CVD or RSD (OR, 0.91; 95% CI, 0.87-0.95), and adverse birth outcomes (OR, 0.94; 95% CI, 0.92-0.96). These associations persisted in all sensitivity and subgroup analyses, except for the country income category, for which a significant reduction was only observed in high-income countries. In meta-analysis, there was no clear association of tax or price increases with adverse health outcomes. However, for the narrative synthesis, all 8 studies reported statistically significant associations between tax increases and decreases in adverse health events.

Conclusions and Relevance

In this systematic review and meta-analysis, smoke-free legislation was associated with significant reductions in morbidity and mortality related to CVD, RSD, and perinatal outcomes. These findings support the need to accelerate the implementation of smoke-free laws to protect populations against smoking-related harm.

Community Interventions for Childhood Asthma ED Visits and Hospitalizations: A Systematic Review

A systematic review of interventions in community environments found significant reductions in childhood asthma exacerbations leading to emergency department visits and hospitalizations.

BACKGROUND AND OBJECTIVES

Structural and social determinants of childhood asthma inequities manifest within geographic communities that are often segregated. Childhood asthma disproportionately affects Black, Hispanic, and low-income populations. Community interventions have the potential to improve inequities in emergency healthcare. This systematic review was conducted to assess the effectiveness of childhood asthma community interventions and provide a conceptual model to inform implementation of future community interventions.

METHODS

Publications from PubMed, ScienceDirect, CINAHL, Cochrane Library, Web of Science, and hand searched references were examined from 2010 to 2021. Community intervention studies among children with asthma were included. Main outcomes were emergency department visits and hospitalizations. Community interventions exclusively focusing on schools or hospitals were excluded. Two reviewers independently assessed eligibility for final inclusion. Emergency healthcare findings were extracted in addition to co-benefits (eg, fewer missed school days and caregiver workdays).

RESULTS

Out of 1856 records, 26 publications met the inclusion criteria. Community interventions were categorized by care coordination (n = 8), policy and environmental changes (eg, smoke-free legislature, traffic reduction models, and green housing) (n = 8), home-based (n = 6), and community-based health services (n = 4). Selected studies indicated that community interventions significantly reduced childhood asthma emergency department visits and hospitalizations through increased caregiver self-efficacy, home environmental trigger reduction, and increased access to healthcare. Because of heterogeneity among studies, we were unable to conduct a meta-analysis.

CONCLUSIONS

Findings show significant associations between community interventions and the reduction of emergency healthcare, suggesting a protective effect for severe cases of childhood asthma.

Hard to Reach or Just Not Enough? A Narrative Review of Inpatient Tobacco Cessation Programs in Pediatrics

Caregiver smoking is a significant risk factor for children with acute and chronic diseases. Hospitalization presents an opportunity to explore caregiver smoking as a modifiable risk factor during a time of crisis when the motivation to change could be heightened. To date, there has not been a published review on inpatient smoking cessation interventions in pediatrics that focus on supporting caregivers of hospitalized children. The goals of this review were to identify and assess the reach and efficacy of tobacco cessation strategies implemented across inpatient units in pediatrics and mother-baby units. This review also proposes clinical and research implications along with program-building recommendations that can help inform future practice in tobacco cessation. A narrative review of the literature identified 14 peer-reviewed studies that described smoking cessation interventions between 2002 and 2021. There were five randomized controlled trials, seven prospective studies, and one retrospective study. The primary kinds of interventions were counseling to heighten caregiver contemplation to quit (n = 12), provision of Nicotine Replacement Therapy (NRT) medications (n = 7), and follow-up with the local Quitline (n = 12). A diverse range of deliverers implemented interventions across studies. Variation in defining quit attempts along with tobacco reduction and cessation outcomes contributed to mixed findings across studies.

Effect of smoke-free legislation on respiratory health services use in children with asthma: a population-based open cohort study in Ontario, Canada

OBJECTIVE

This study will add to existing literature by examining the impact of smoke-free legislation in outdoor areas among children with asthma. We aimed to examine the effect of the 2015 Smoke-Free Ontario Act (SFOA) amendment, which prohibited smoking on patios, playgrounds and sports fields, on health services use (HSU) rates in children with asthma.

METHODS

We conducted a population-based open cohort study using health administrative data from the province of Ontario, Canada. Each year, all Ontario residents aged 0-18 years with physician diagnosed asthma were included in the study. Annual rates of HSU (emergency department (ED) visits, hospitalisations and physician office visits) for asthma and asthma-related conditions (eg, bronchitis, allergic rhinitis, influenza and pneumonia) were calculated. Interrupted time-series analysis, accounting for seasonality, was used to estimate changes in HSU following the 2015 SFOA.

RESULTS

The study population ranged from 618 957 individuals in 2010 to 498 812 in 2018. An estimated average increase in ED visits for asthma in infants aged 0-1 years of 0.42 per 100 individuals (95% CI: 0.09 to 0.75) and a 57% relative increase corresponding to the 2015 SFOA was observed. A significant decrease in ED visits for asthma-related conditions of 0.19 per 100 individuals (95% CI: -0.37 to -0.01) and a 22% relative decrease corresponding to the 2015 SFOA was observed.

CONCLUSION

Based on the observed positive effect of restricting smoking on patios, playgrounds and sports fields on respiratory morbidity in children with asthma, other jurisdictions globally should consider implementing similar smoke-free policies.

Associations between smoke-free vehicle legislation and childhood admissions to hospital for asthma in Scotland: an interrupted time-series analysis of whole-population data

BACKGROUND

In Scotland, childhood admissions to hospital for asthma fell from March, 2006, after legislation was introduced to prohibit smoking in public places. In December, 2016, new Scottish legislation banned smoking in vehicles containing a child. We aimed to determine whether the introduction of this new legislation produced additional benefits.

METHODS

We obtained data on all asthma emergency admissions to hospitals in Scotland between 2000 and 2018 for individuals younger than 16 years. We used interrupted time-series analyses to study changes in monthly incidence of asthma emergency admissions to hospital per 100 000 children after the introduction of smoke-free vehicle legislation, taking into account previous smoke-free interventions. We did subgroup analyses according to age and area deprivation, using the Scottish Index of Multiple Deprivation, and repeated the analyses for a control condition, gastroenteritis, and other respiratory conditions.

FINDINGS

Of the 32 342 emergency admissions to hospital for asthma among children younger than 16 years over the 19-year study period (Jan 1, 2000, to Dec 31, 2018), 13 954 (43%) were among children younger than 5 years and 18 388 (57%) were among children aged 5-15 years. After the introduction of smoke-free vehicle legislation, there was a non-significant decline in the slope for monthly emergency admissions to hospital for asthma among children younger than 16 years (-1·21%, 95% CI -2·64 to 0·23) relative to the underlying trend in hospital admissions for childhood asthma. However, children younger than 5 years had a significant decline in the slope for monthly asthma admissions (-1·49%, -2·69 to -0·27) over and above the underlying trend among children in this age group (equivalent to six fewer hospitalisations per year), but no such decline was seen in children aged 5-15 years. Monthly admissions to hospital for asthma fell significantly among children living in the most affluent areas (-2·27%, -4·41 to -0·07) but not among those living in the most deprived areas. We found no change in admissions to hospital for gastroenteritis or other respiratory conditions after the introduction of the smoke-free vehicle legislation.

INTERPRETATION

Although legislation banning smoking in vehicles did not affect hospital admissions for severe asthma among children overall or in the older age group, this legislation was associated with a reduction in severe asthma exacerbations requiring hospital admission among preschool children, over and above the underlying trend and previous interventions designed to reduce exposure to second-hand smoke. Similar legislation prohibiting smoking in vehicles that contain children should be adopted in other countries.

FUNDING

None.

Burden of disease from exposure to secondhand smoke in children in Europe

BACKGROUND

Secondhand smoke (SHS) exposure at home and fetal SHS exposure during pregnancy are a major cause of disease among children. The aim of this study is quantifying the burden of disease due to SHS exposure in children and in pregnancy in 2006-2017 for the 28 European Union (EU) countries.

METHODS

Exposure to SHS was estimated using a multiple imputation procedure based on the Eurobarometer surveys, and SHS exposure burden was estimated with the comparative risk assessment method using meta-analytical relative risks. Data on deaths and disability-adjusted life years (DALYs) were collected from National statistics and from the Global Burden of Disease Study.

RESULTS

Exposure to SHS and its attributable burden stalled in 2006-2017; in pregnant women, SHS exposure was 19.8% in 2006, 19.1% in 2010, and 21.0% in 2017; in children it was 10.1% in 2006, 9.6% in 2010, and 12.1% in 2017. In 2017, 35,633 DALYs among children were attributable to SHS exposure in the EU, mainly due to low birth weight.

CONCLUSIONS

Comprehensive smoking bans up to 2010 contributed to reduce SHS exposure and its burden in children immediately after their implementation; however, SHS exposure still occurs, and in 2017, its burden in children was still relevant.

IMPACT

Exposure to secondhand smoke at home and in pregnancy is a major cause of disease among children. Smoking legislation produced the adoption of voluntary smoking bans in homes; however, secondhand smoke exposure at home still occurs and its burden is substantial. In 2017, the number of deaths and disability-adjusted life years in children attributable to exposure to secondhand smoke in the European Union countries were, respectively, 335 and 35,633. Low birth weight caused by secondhand smoke exposure in pregnancy showed the largest burden. Eastern European Union countries showed the highest burden.

Regional differences in pediatric asthma hospital admissions: National data from Israel 1996-2017

BACKGROUND

Asthma is a common chronic childhood illness and frequent cause of hospitalization. A decline in hospital admission rates was noted up to the 1990s, however, trends are not as clear since the turn of the century. This study aimed to assess the rates and regional differences of asthma admissions over more than two decades using the national Ministry of Health database, which registers data from all the hospitals.

METHODS

A retrospective cohort study, analysis of all pediatric asthma admissions, for Patients 1-14 years old, between 1996 and 2017 as recorded by the National Hospital Discharge Registry, was performed. Asthma admission rates were calculated per 1000 age adjusted residents, using the number of admission cases as the numerator, and age specific population size as the denominator.

RESULTS

The annual asthma hospitalization rate decreased in the entire pediatric population from 2.14 in 1996-0.89 in 2017. Children in the 1-4 year age group comprised most of the hospital admissions, and most of the decline was attributable to this age group. Significant differences in hospitalizations were found between different regions as well as differences in the rate of decline in asthma hospitalizations with the lowest admission rate in the Jerusalem district, highest in Haifa, northern and southern Israeli regions and the greatest rate of decline in the Tel-Aviv district.

CONCLUSION

This nationwide study, over more than two decades, shows clear regional differences in the rates of asthma admissions as well as regional differences in the rates of decline.

Associations between a smoke-free homes intervention and childhood admissions to hospital in Scotland: an interrupted time-series analysis of whole-population data

BACKGROUND

Many children are exposed to second-hand smoke in the home and are at increased risk of asthma and other respiratory conditions. In Scotland, a public health mass-media campaign was launched on March 24, 2014, called Take it Right Outside (TiRO), with a focus on reducing the exposure of children to domestic second-hand smoke. In this study, our aim was to establish whether the TiRO campaign was followed by a decrease in hospital admissions for childhood asthma and other respiratory conditions related to second-hand smoke exposure across Scotland.

METHODS

For an interrupted time-series analysis, data were obtained on all hospital admissions in Scotland between 2000 and 2018 for children aged younger than 16 years. We studied changes in the monthly incidence of admissions for conditions potentially related to second-hand smoke exposure (asthma, lower respiratory tract infection, bronchiolitis, croup, and acute otitis media) per 1000 children following the 2014 TiRO campaign, while considering national legislation banning smoking in public spaces from 2006. We considered asthma to be the primary condition related to second-hand smoke exposure, with monthly asthma admissions as the primary outcome. Gastroenteritis was included as a control condition. The analysis of asthma admissions considered subgroups stratified by age and area quintile of the Scottish Index of Multiple Deprivations (SIMD).

FINDINGS

740 055 hospital admissions were recorded for children. 138 931 (18·8%) admissions were for respiratory conditions potentially related to second-hand smoke exposure, of which 32 342 (23·3%) were for asthma. After TiRO in 2014, we identified a decrease relative to the underlying trend in the slope of admissions for asthma (-0·48% [-0·85 to -0·12], p=0·0096) in younger children (age <5 years), but not in older children (age 5-15 years). Asthma admissions did not change after TiRO among children 0-15 years of age when data were analysed according to area deprivation quintile. Following the 2006 legislation, independent of TiRO, asthma admissions decreased in both younger children (-0·36% [-0·67 to -0·05], p=0·021) and older children (-0·68% [-1·00 to -0·36], p<0·0001), and in children from the most deprived (SIMD 1; -0·49% [-0·87 to -0·11], p=0·011) and intermediate deprived (SIMD 3; -0·70% [-1·17 to -0·23], p=0·0043) area quintiles, but not in those from the least deprived (SIMD 5) area quintile.

INTERPRETATION

Our findings suggest that smoke-free home interventions could be an important tool to reduce asthma admissions in young children, and that smoke-free public space legislation might improve child health for many years, especially in the most deprived communities.

FUNDING

University of Aberdeen Research Excellence Framework 2021 Impact Support Award Scheme.

Smoking, SARS-CoV-2 and COVID-19: A review of reviews considering implications for public health policy and practice

INTRODUCTION

There has been significant speculation regarding the association between the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) pathogen, coronavirus disease (COVID-19) and smoking. We provide an overview of the available literature regarding the association between smoking, risk of SARS-CoV-2 infection, and risk of severe COVID-19 and poor clinical outcomes, with the aim of informing public health policy and practice, particularly in England.

METHODS

Publications were identified utilising a systematic search approach on PUBMED and Google Scholar. Publications presenting a systematic review or meta-analysis considering the association between smoking and SARS-COV-2 infection or COVID-19 outcomes were included.

RESULTS

Eight studies were identified. One considered the relationship between smoking and the probability of SARS-CoV-2 infection, three considered the association between COVID-19 hospitalisation and smoking history, and six reviewed the association between smoking history and development of severe COVID-19. One study specifically investigated the risk of mortality. The studies considering risk of severe disease indicate that there is a significant association between COVID-19 and current or ever smoking.

CONCLUSIONS

This is a rapidly evolving topic. Current analysis remains limited due to the quality of primary data, although, early results indicate an association between smoking and COVID-19 severity. We highly recommend public health messaging to continue focusing on smoking cessation efforts.

The impact of anti-tobacco legislation on birth weight in Peru

Background

Tobacco exposure remains a significant issue for public health, especially for pregnant women. It increases the risk for premature labor, low birth weight and small for gestational age (SGA), among other effects. To reduce these risks, many countries have enacted public policies to curb tobacco exposure. Peru enacted anti-tobacco laws that forbid smoking in public places, require prevention text and images in products and publicity, along with restriction of sales to adults. We evaluated the effect of the implementation of this law on newborn outcomes: birth weight, prematurity and SGA.

Methods

This was a quasi-experimental study that utilized data from the Peruvian Live Birth Registry. Children born to mothers from urban areas were the intervention group, while children born to mothers from rural areas were considered the control group. Only singletons with information on birth weight and gestational age, born to mothers aged 12 to 49 years were included in the study. In addition, newborns with birth weights greater than + 4 standard deviations (SD) or less than - 4 SD from the gestational age-specific mean were excluded. To measure the effect of legislation on birth weight we performed a difference in differences analysis.

Results

A total of 2,029,975 births were included in the analysis. After adjusting for characteristics of the mother and the child, and contextual variables, the anti-tobacco law in Peru reduced the incidence of prematurity by 30 cases per 10,000 live births (95% CI: 19 to 42).

Conclusions

The reform had negligible effects on overall birth weights and on the incidence of SGA. This modest result suggests the need for a more aggressive fight against tobacco, prohibiting all types of advertising and promotion of tobacco products, among others measures.

Parental Smoking and Under-Five Child Mortality in Southeast Asia: Evidence from Demographic and Health Surveys

Smoking remains the main cause of preventable early death. However, little is known about the association between parental smoking and child mortality in under-fives in developing countries. This study assesses the association between parental smoking status, smoking amount and smoking frequency with child mortality in under-fives in four Southeast Asian countries (Cambodia, Indonesia, Lao People’s Democratic Republic and Timor Leste). We used the Demographic and Health Survey dataset. The information from couples consisting of fathers and mothers (n = 19,301 couples) in the same household were collected. Under-five child mortality was significantly associated with paternal smoking only (odds ratio (OR) = 1.25, 95% confidence interval (CI): 1.14–1.38), maternal smoking only (OR = 2.40, 95% CI: 1.61–3.59) and both parents smoking (OR = 2.60, 2.08–3.26). Paternal, maternal, both parents’ smoking amount and frequency were also assessed. The estimated association decreased after adjusting for covariates but remained highly significant for smoking in both parents, mothers who smoked 1–10 cigarettes/day, when both parents smoked > 20 cigarettes/day, and in mothers who smoked every day. Future behavioural changes and smoking cessation programmes should engage parents as a catalyst for the reduction of child mortality risk in LMICs in the SEA region.

Investigating the effect of England's smoke-free private vehicle regulation on changes in tobacco smoke exposure and respiratory disease in children: a quasi-experimental study

BACKGROUND

Comprehensive tobacco control policies can help to protect children from tobacco smoke exposure and associated adverse respiratory health consequences. We investigated the impact of England's 2015 regulation that prohibits smoking in a private vehicle with children present on changes in environmental tobacco smoke exposure and respiratory health in children.

METHODS

In this quasi-experimental study, we used repeated cross-sectional, nationally representative data from the Health Survey for England from Jan 1, 2008, to Dec 31, 2017, of children aged up to 15 years. We did interrupted time series logistic or ordinal regression analyses to assess changes in prevalence of self-reported respiratory conditions, prevalence of self-reported childhood tobacco smoke exposure (children aged 8-15 years only), and salivary cotinine levels (children aged 2 years or older) before and after implementation of the smoke-free private vehicle regulation on Oct 1, 2015. Children who were considered active smokers were excluded from the analyses of salivary cotinine levels. Our primary outcome of interest was self-reported current wheezing or asthma, defined as having medicines prescribed for these conditions. Analyses were adjusted for underlying time trends, quarter of year, sex, age, Index of Multiple Deprivation quintile, and urbanisation level.

FINDINGS

21 096 children aged 0-15 years were included in our dataset. Implementation of the smoke-free private vehicle regulation was not associated with a demonstrable change in self-reported current wheezing or asthma (adjusted odds ratio 0·81, 95% CI 0·62-1·05; p=0·108; assessed in 13 369 children), respiratory conditions (1·02, 0·80-1·29; p=0·892; assessed in 17 006 children), or respiratory conditions probably affecting stamina, breathing, or fatigue (0·75, 0·47-1·19; p=0·220; assessed in 12 386 children). Self-reported tobacco smoke exposure and salivary cotinine levels generally decreased over the study period. There was no additional change in self-reported tobacco smoke exposure in cars among children aged 8-15 years following the legislation (0·77, 0·51-1·17; p=0·222; assessed in 5399 children). We observed a relative increase in the odds of children having detectable salivary cotinine levels post legislation (1·36, 1·09-1·71; p=0·0074; assessed in 7858 children) and levels were also higher (1·30, 1·04-1·62; p=0·020; ordinal variable). Despite introduction of the regulation, one in 20 children still reported being regularly exposed to tobacco smoke in cars and one in three still had detectable salivary cotinine levels.

INTERPRETATION

We found no demonstrable association between the implementation of England's smoke-free private vehicle regulation and changes in children's self-reported tobacco smoke exposure or respiratory health. There is an urgent need to develop more effective approaches to protect children from tobacco smoke in various places, including in private vehicles.

FUNDING

Netherlands Lung Foundation, Erasmus MC, Farr Institute, Health Data Research UK, Asthma UK Centre for Applied Research, Academy of Medical Sciences, and Newton Fund.

[Prevalence of smoke-free homes and passive exposure to tobacco in pediatric population (children from 3 to 36 months)]

OBJECTIVE

Pediatric population is the most vulnerable to secondhand smoke (SHS), exposure being households the main source of exposure in children. The objective of this study is to describe smoke-free households and the prevalence of SHS in the pediatric population (from 3 to 36 months) in Spain.

METHODS

Cross-sectional study with 1,368 parents, mothers or guardians with children from 3 to 36 months carried out in Spain from March to November of 2017 through an online questionnaire as part of the EPISON study. Information was collected on the voluntary adoption of tobacco use regulations at home and SHS exposure at home and other environments. We calculated prevalences and Odds Ratio adjusted (ORa) for sex, age, level of education, and smoking status.

RESULTS

87.6% of respondents claimed to have a smoke-free home. 12.4% of respondents had partial regulation or did not have regulation at home, increasing up to 26.0% when the parent was a smoker or to 21.8% when the parent had primary or lower education. 5.4% of parents reported SHS exposure in their children at their homes, rising to 14.5% when it occurs in other environments, increasing with statistically significant differences between smoking parents and parents with lower educational level.

CONCLUSIONS

The smoke-free homes are the majority; but SHS exposure to tobacco at home persists in children under 3 years of age, especially in families with a lower educational level. Therefore, awareness-raising campaigns on the effects of passive exposure on minors among families with.

Higher parental education was associated with better asthma control

Aim

Inhaled corticosteroids have resulted in the improved control of asthma and a reduced need for hospitalisation. This study aimed to examine the prevalence of uncontrolled asthma and factors that affect asthma control.

Methods

The data came from a longitudinal cohort study of children. The parents answered questionnaires from age 6 months to 12 years. The response rate at age 12 years was 76% (3637/4777) and doctor‐diagnosed asthma was reported in 6.4% (n = 233). Asthma control was examined with the Asthma Control Test (ACT), where scores below 20 denote uncontrolled asthma.

Results

Of the children with asthma at age 12 years, 15% had an ACT value below 20, that is uncontrolled asthma. Independent risk factors for uncontrolled asthma were wheeze triggered by exercise (adjusted OR, aOR 5.6; 1.9–16.6), cat at home (aOR 3.5; 1.2–10.0) and current doctor‐diagnosed rhinitis (aOR 2.8; 95% CI 1.1–7.0). A higher education in the parents reduced the risk of uncontrolled asthma (aOR 0.3; 95% CI 0.1–0.8). Only six children (i.e. 2.6%) reported hospitalisation due to asthma during the last year.

Conclusion

Of the children with asthma, 15% had uncontrolled asthma. Higher education in the parents was associated with better asthma control in the children.

Impact of India's National Tobacco Control Programme on bidi and cigarette consumption: a difference-in-differences analysis

Background

Despite the importance of decreasing tobacco use to achieve mortality reduction targets of the Sustainable Development Goals in low-income and middle-income countries (LMICs), evaluations of tobacco control programmes in these settings are scarce. We assessed the impacts of India’s National Tobacco Control Programme (NTCP), as implemented in 42 districts during 2007–2009, on household-reported consumption of bidis and cigarettes.

Methods

Secondary analysis of cross-sectional data from nationally representative Household Consumer Expenditure Surveys (1999–2000; 2004–2005 and 2011–2012). Outcomes were: any bidi/cigarette consumption in the household and monthly consumption of bidi/cigarette sticks per person. A difference-in-differences two-part model was used to compare changes in bidi/cigarette consumption between NTCP intervention and control districts, adjusting for sociodemographic characteristics and time-based heterogeneity.

Findings

There was an overall decline in household-reported bidi and cigarette consumption between 1999–2000 and 2011–2012. However, compared with control districts, NTCP districts had no significantly different reductions in the proportions of households reporting bidi (adjusted OR (AOR): 1.03, 95% CI: 0.84 to 1.28) or cigarette (AOR: 1.01 to 95% CI: 0.82 to 1.26) consumption, or for the monthly per person consumption of bidi (adjusted coefficient: 0.07, 95% CI: −0.13 to 0.28) or cigarette (adjusted coefficient: −0.002, 95% CI: −0.26 to 0.26) sticks among bidi/cigarette consuming households.

Interpretation

Our findings indicate that early implementation of the NTCP may not have produced reductions in tobacco use reflecting generally poor performance against the Framework Convention for Tobacco Control objectives in India. This study highlights the importance of strengthening the implementation and enforcement of tobacco control policies in LMICs to achieve national and international child health and premature NCD mortality reduction targets.

Tobacco Control Laws and Pediatric Asthma

BACKGROUND

Exposure to environmental tobacco smoke increases pediatric asthma severity. Strict, state-level tobacco control reduces smoking. The Child Asthma Call-Back Survey (Child ACBS) is a nationally representative survey of the guardians of children with asthma. The American Lung Association's annual State of Tobacco Control report grades tobacco control laws in each state including a tax grade (cigarette excise tax relative to the national mean), and a smoke-free air grade (number of locations where smoking is prohibited).

METHODS

We joined Child ACBS data from 2006 to 2010 with corresponding state and year tobacco grades. In the primary analysis, we investigated the effect of state tax grades on a child's asthma severity by using a logistic regression model adjusting for year. A secondary analysis assessed the impact of smoke-free air grades on in-home smoking.

RESULTS

Our analysis included 12 860 Child ACBS interviews from 35 states over 5 years, representing over 24 million individuals. We merged 112 unique State of Tobacco Control grades with patient data by state and year. A higher tax grade was associated with reduced severity (adjusted odds ratio = 1.40; P = .007, 95% confidence interval: 1.10-1.80). A better smoke-free air grade was not associated with decreased in-home smoking after adjusting for confounding by income and type of residence.

CONCLUSIONS

A stronger tobacco tax is associated with reduced asthma severity. Further study is needed to determine the effect of smoke-free air laws on in-home environmental. This work supports ongoing efforts to strengthen tobacco control through federal and state regulations.

Time to Asthma-Related Readmission in Children Admitted to the ICU for Asthma

OBJECTIVES

To compare the time to asthma-related readmissions between children with a previous ICU hospitalization for asthma and those with a non-ICU hospitalization and to explore predictors of time to readmission in children admitted to the ICU.

DESIGN

Retrospective cohort study using a pan-Canadian administrative inpatient database from April 1, 2008, to March 31, 2014.

SETTING

All adult and pediatric Canadian hospitals.

SUBJECTS

Children 2-17 years old with a hospitalization for asthma.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total of 26,168 children were hospitalized 33,304 times during the study period. The time to readmission was shorter in the ICU group compared with the non-ICU group (median time to readmission 27 mo in ICU vs 35 mo in non-ICU group). Preschool-aged children (hazard ratio, 1.48; 95% CI, 1.02-2.14) and increased length of stay (hazard ratio, 1.63; 95% CI, 1.17-2.27) were associated with a shorter time to readmission.

CONCLUSIONS

Children previously admitted to the ICU for asthma had a shorter time to asthma-related readmission, compared with children who did not require intensive care, underlining the importance of targeted long-term postdischarge follow-up of these children. Children of preschool age and who have a lengthier hospital stay are particularly at risk for future morbidity.

Smoke-free homes and attitudes towards banning smoking in vehicles carrying children in Spain (2016)

OBJECTIVE

To describe the voluntary adoption of smoke-free homes and social attitudes in Spain towards banning smoking in vehicles in which children are present.

METHODS

Cross-sectional study of a representative sample of the adult Spanish population age range, 18-75 years (n=1036). The field work was conducted via a computer-assisted telephone survey in March and April 2016. Survey respondents answered questions about smoking rules at home and attitudes towards a smoking ban in cars with or without children. Home smoking rules were defined as complete (smoking not allowed anywhere in the house), partial (smoking allowed in some areas inside the house) or absent (smoking allowed everywhere).

RESULTS

Most (83.0%) of the surveyed population had some type of smoking restriction in place at home (45.6% complete and 37.5% partial). There were significant differences between groups according to age group (the highest prevalence was 86.1% from 66 to 75 years and the lowest prevalence was 77.8% from 46 to 65 years) and smoking status (the highest prevalence was 89.4% in people who had never been smokers and the lowest prevalence was 75.0% in current smokers) with regards to the prevalence of smoke-free homes (p<0.05), with partial bans more prevalent in smoking households (49.0%). Most (61.6%) of the population favored banning smoking in cars, and 90.1% supported a ban in cars carrying minors. Attitudes towards smoking regulation in cars (with or without children) varied significantly by age group (the highest prevalence was 81.9% from 66 to 75 years and the lowest prevalence was 54.5% from 18 to 45 years) and smoking status (the highest prevalence was 71.4% in people who had never been smokers and the lowest prevalence was 46.0% in current smokers). However, no significant differences were found with regard to attitudes towards smoking regulation in cars carrying children, regardless of sex, age, social class, or smoking status.

CONCLUSION

Approximately half of the adult population in Spain have implemented a complete smoke-free rule at home. More than 9 out of 10 adults favor regulating smoking in cars in the presence of minors. These findings support the expansion of smoke-free regulations to include private vehicles, particularly when minors are in the car.

Effect of tobacco control policies on perinatal and child health: a systematic review and meta-analysis

BACKGROUND

Tobacco smoking and smoke exposure during pregnancy and childhood cause considerable childhood morbidity and mortality. We did a systematic review and meta-analysis to investigate whether implementation of WHO's recommended tobacco control policies (MPOWER) was of benefit to perinatal and child health.

METHODS

We searched 19 electronic databases, hand-searched references and citations, and consulted experts to identify studies assessing the association between implementation of MPOWER policies and child health. We did not apply any language restrictions, and searched the full time period available for each database, up to June 22, 2017. Our primary outcomes of interest were perinatal mortality, preterm birth, hospital attendance for asthma exacerbations, and hospital attendance for respiratory tract infections. Where possible and appropriate, we combined data from different studies in random-effects meta-analyses. This study is registered with PROSPERO, number CRD42015023448.

FINDINGS

We identified 41 eligible studies (24 from North America, 16 from Europe, and one from China) that assessed combinations of the following MPOWER policies: smoke-free legislation (n=35), tobacco taxation (n=11), and smoking cessation services (n=3). Risk of bias was low in 23 studies, moderate in 16, and high in two. Implementation of smoke-free legislation was associated with reductions in rates of preterm birth (-3·77% [95% CI -6·37 to -1·16]; ten studies, 27 530 183 individuals), rates of hospital attendance for asthma exacerbations (-9·83% [-16·62 to -3·04]; five studies, 684 826 events), and rates of hospital attendance for all respiratory tract infections (-3·45% [-4·64 to -2·25]; two studies, 1 681 020 events) and for lower respiratory tract infections (-18·48% [-32·79 to -4·17]; three studies, 887 414 events). Associations appeared to be stronger when comprehensive smoke-free laws were implemented than when partial smoke-free laws were implemented. Among two studies assessing the association between smoke-free legislation and perinatal mortality, one showed significant reductions in stillbirth and neonatal mortality but did not report the overall effect on perinatal mortality, while the other showed no change in perinatal mortality. Meta-analysis of studies on other MPOWER policies was not possible; all four studies on increasing tobacco taxation and one of two on offering disadvantaged pregnant women help to quit smoking that reported on our primary outcomes had positive findings. Assessment of publication bias was only possible for studies assessing the association between smoke-free legislation and preterm birth, showing some degree of bias.

INTERPRETATION

Smoke-free legislation is associated with substantial benefits to child health. The majority of studies on other MPOWER policies also indicated a positive effect. These findings provide strong support for implementation of such policies comprehensively across the world.

FUNDING

Chief Scientist Office Scotland, Farr Institute, Netherlands Lung Foundation, Erasmus MC.

Involving mosques in health promotion programmes: a qualitative exploration of the MCLASS intervention on smoking in the home

Second-hand smoke (SHS) exposure is high among UK Bangladeshi and Pakistani populations, reflecting higher male smoking prevalence and fewer home smoking restrictions than the general population. The Muslim Communities Learning About Second-hand Smoke (MCLASS) study explored the feasibility and acceptability of implementing SHS education in 14 UK mosques. Religious teachers (RTs) in seven intervention mosques were trained and provided with a culturally appropriate educational package. After the intervention, mosque leaders, RTs and congregants' experiences and perceptions of the intervention were explored through interviews and focus group discussions. Delivery of the intervention varied across mosques. Facilitators and barriers included: mosque diversity (congregation size, organizational structure, educational activities, women's role and involvement); degree of trust between researchers and personnel; and views on SHS. Most participants thought mosques' involvement in SHS health promotion was appropriate, but the perceived importance of SHS differed. We found that a health promotion programme delivered within Islamic religious settings that engages RTs in the process of facilitation, can be acceptable and feasible, but care must be taken to explore the culture and ethos of the institution, including its organizational structure, management committee, RTs and congregation.

Smokefree legislation effects on respiratory and sensory disorders: A systematic review and meta-analysis

Aims

The aim of this systematic review and meta-analysis is to synthesize the available evidence in scientific papers of smokefree legislation effects on respiratory diseases and sensory and respiratory symptoms (cough, phlegm, red eyes, runny nose) among all populations.

Materials and methods

Systematic review and meta-analysis were carried out. A search between January 1995 and February 2015 was performed in PubMed, EMBASE, Cochrane Library, Scopus, Web of Science, and Google Scholar databases. Inclusion criteria were: 1) original scientific studies about smokefree legislation, 2) Data before and after legislation were collected, and 3) Impact on respiratory and sensory outcomes were assessed. Paired reviewers independently carried out the screening of titles and abstracts, data extraction from full-text articles, and methodological quality assessment.

Results

A total number of 1606 papers were identified. 50 papers were selected, 26 were related to symptoms (23 concerned workers). Most outcomes presented significant decreases in the percentage of people suffering from them, especially in locations with comprehensive measures and during the immediate post-ban period (within the first six months). Four (50%) of the papers concerning pulmonary function reported some significant improvement in expiratory parameters. Significant decreases were described in 13 of the 17 papers evaluating asthma hospital admissions, and there were fewer significant reductions in chronic obstructive pulmonary disease admissions (range 1–36%) than for asthma (5–31%). Six studies regarding different respiratory diseases showed discrepant results, and four papers about mortality reported significant declines in subgroups. Low bias risk was present in 23 (46%) of the studies.

Conclusions

Smokefree legislation appears to improve respiratory and sensory symptoms at short term in workers (the overall effect being greater in comprehensive smokefree legislation in sensory symptoms) and, to a lesser degree, rates of hospitalization for asthma.

Changes in hospitalizations for chronic respiratory diseases after two successive smoking bans in Spain

Background

Existing evidence on the effects of smoke-free policies on respiratory diseases is scarce and inconclusive. Spain enacted two consecutive smoke-free regulations: a partial ban in 2006 and a comprehensive ban in 2011. We estimated their impact on hospital admissions via emergency departments for chronic obstructive pulmonary disease (COPD) and asthma.

Methods

Data for COPD (ICD-9 490–492, 494–496) came from 2003–2012 hospital admission records from the fourteen largest provinces of Spain and from five provinces for asthma (ICD-9 493). We estimated changes in hospital admission rates within provinces using Poisson additive models adjusted for long-term linear trends and seasonality, day of the week, temperature, influenza, acute respiratory infections, and pollen counts (asthma models). We estimated immediate and gradual effects through segmented-linear models. The coefficients within each province were combined through random-effects multivariate meta-analytic models.

Results

The partial ban was associated with a strong significant pooled immediate decline in COPD-related admission rates (14.7%, 95%CI: 5.0, 23.4), sustained over time with a one-year decrease of 13.6% (95%CI: 2.9, 23.1). The association was consistent across age and sex groups but stronger in less economically developed Spanish provinces. Asthma-related admission rates decreased by 7.4% (95%CI: 0.2, 14.2) immediately after the comprehensive ban was implemented, although the one-year decrease was sustained only among men (9.9%, 95%CI: 3.9, 15.6).

Conclusions

The partial ban was associated with an immediate and sustained strong decline in COPD-related admissions, especially in less economically developed provinces. The comprehensive ban was related to an immediate decrease in asthma, sustained for the medium-term only among men.

Factors associated with childhood asthma control in a resource-poor center

Introduction:

Optimal asthma control is a major aim of childhood asthma management. This study aimed to determine factors associated with suboptimal asthma control at the pediatric chest clinic of a resource-poor center.

Methods:

Over a 12-month study period, children aged 2–14 years with physician-diagnosed asthma attending the pediatric chest clinic of the Wesley Guild Hospital (WGH), Ilesa, Nigeria were consecutively recruited. Asthma control was assessed using childhood asthma control questionnaire. Partly and uncontrolled asthma was recorded as a suboptimal control. Relevant history and examinations findings were compared between children with good and suboptimal asthma control. Binary logistic regression analysis was used to determine the predictors of suboptimal asthma control.

Results:

A total of 106 children participated in the study with male:female ratio of 1.5:1, and majority (83.0%) had mild intermittent asthma. Suboptimal asthma control was observed in 19 (17.9%) of the children. Household smoke exposure, low socioeconomic class, unknown triggers, concomitant allergic rhinoconjunctivitis, and poor parental asthma knowledge, were significantly associated with suboptimal control (P < 0.05). Low socioeconomic class (odds ratio [OR] =6.231; 95% confidence interval [CI] =1.022–8.496; P = 0.005) and poor parental asthma knowledge (OR = 7.607; 95% CI = 1.011–10.481; P = 0.007) independently predict suboptimal control.

Conclusion:

Approximately, one in five asthmatic children attending the WGH pediatric chest clinic who participated in the study had suboptimal asthma control during the study. More comprehensive parental/child asthma education and provision of affordable asthma care services may help improve asthma control among the children.

Indoor tobacco legislation is associated with fewer emergency department visits for asthma exacerbation in children

BACKGROUND

During the past 3 decades, numerous cities and states have adopted laws that ban smoking in public indoor spaces. The rationale for these policies has been to protect nonsmokers from the adverse health effects of secondhand smoke.

OBJECTIVE

To determine whether the implementation of indoor smoking legislation is associated with a decrease in emergency department visits for asthma in children.

METHODS

This retrospective analysis used a natural experiment to estimate the impact of clean indoor air legislation on the rate of emergency department admissions for asthma exacerbation in children. Data were obtained from the Pediatric Health Information System. A Poisson regression was used for analyses and controlled for age, sex, race, payer source, seasonality, and secular trends.

RESULTS

Asthma emergency department visits were captured from 20 hospitals in 14 different states plus the District of Columbia from July 2000 to January 2014 (n = 335,588). Indoor smoking legislation, pooled across all cities, was associated with a decreased rate of severe asthma exacerbation (adjusted rate ratio 0.83, 95% confidence interval 0.82-0.85, P < .0001).

CONCLUSION

Indoor tobacco legislation is associated with a decrease in emergency department visits for asthma exacerbation. Such legislation should be considered in localities that remain without this legislation to protect the respiratory health of their children.

Smoke-free legislation and child health

In this paper, we aim to present an overview of the scientific literature on the link between smoke-free legislation and early-life health outcomes. Exposure to second-hand smoke is responsible for an estimated 166 ,000 child deaths each year worldwide. To protect people from tobacco smoke, the World Health Organization recommends the implementation of comprehensive smoke-free legislation that prohibits smoking in all public indoor spaces, including workplaces, bars and restaurants. The implementation of such legislation has been found to reduce tobacco smoke exposure, encourage people to quit smoking and improve adult health outcomes. There is an increasing body of evidence that shows that children also experience health benefits after implementation of smoke-free legislation. In addition to protecting children from tobacco smoke in public, the link between smoke-free legislation and improved child health is likely to be mediated via a decline in smoking during pregnancy and reduced exposure in the home environment. Recent studies have found that the implementation of smoke-free legislation is associated with a substantial decrease in the number of perinatal deaths, preterm births and hospital attendance for respiratory tract infections and asthma in children, although such benefits are not found in each study. With over 80% of the world’s population currently unprotected by comprehensive smoke-free laws, protecting (unborn) children from the adverse impact of tobacco smoking and SHS exposure holds great potential to benefit public health and should therefore be a key priority for policymakers and health workers alike.

Disadvantaged Parents' Engagement with a National Secondhand Smoke in the Home Mass Media Campaign: A Qualitative Study

Mass media campaigns can be effective in tobacco control but may widen health inequalities if they fail to engage disadvantaged smokers. This qualitative study explored how parents with young children living in disadvantaged circumstances engaged with a national campaign which aimed to raise awareness of the importance of smokefree homes. Individual semi-structured interviews were carried out with 17 parents before and after the Scottish 2014 “Right Outside” mass media campaign. A conceptual framework exploring meaningful exposure (recall and understanding), motivational responses (protecting children from secondhand smoke (SHS)) and opportunities to act (barriers) was used to thematically analyse the findings. Campaign recall and engagement, and motivation to protect children were high. Parents identified with the dramatized scenario and visual impact of SHS harm to children in the TV advertisement. Some reported changed smoking practices. However, supervising young children in limited accommodation when caring alone constrained opportunities to smoke outside. Instead, parents described actions other than smoking outside that they had taken or were planning to take to create smokefree homes. Mass media campaigns using emotive, real-life circumstances can be effective in engaging parents about SHS. However, the behavioural impact may be limited because of difficult home environments and circumstances.

Reduction in emergency department visits for children's asthma, ear infections, and respiratory infections after the introduction of state smoke-free legislation

Despite the benefits of smoke-free legislation on adult health, little is known about its impact on children's health. We examined the effects of tobacco control policies on the rate of emergency department (ED) visits for childhood asthma (N=128,807), ear infections (N=288,697), and respiratory infections (N=410,686) using outpatient ED visit data in Massachusetts (2001-2010), New Hampshire (2001-2009), and Vermont (2002-2010). We used negative binomial regression models to analyze the effect of state and local smoke-free legislation on ED visits for each health condition, controlling for cigarette taxes and health care reform legislation. We found no changes in the overall rate of ED visits for asthma, ear infections, and upper respiratory infections after the implementation of state or local smoke-free legislation or cigarette tax increases. However, an interaction with children's age revealed that among 10-17-year-olds state smoke-free legislation was associated with a 12% reduction in ED visits for asthma (adjusted incidence rate ratios (aIRR) 0.88; 95% CI 0.83, 0.95), an 8% reduction for ear infections (0.92; 0.88, 0.97), and a 9% reduction for upper respiratory infections (0.91; 0.87, 0.95). We found an overall 8% reduction in ED visits for lower respiratory infections after the implementation of state smoke-free legislation (0.92; 0.87, 0.96). The implementation of health care reform in Massachusetts was also associated with a 6-9% reduction in all children's ED visits for ear and upper respiratory infections. Our results suggest that state smoke-free legislation and health care reform may be effective interventions to improve children's health by reducing ED visits for asthma, ear infections, and respiratory infections.

Clinical Decision Support Tool for Parental Tobacco Treatment in Hospitalized Children

OBJECTIVES

To create and evaluate the feasibility, acceptability, and usability of a clinical decision support (CDS) tool within the electronic health record (EHR) to help pediatricians provide smoking cessation counseling and treatment to parents of hospitalized children exposed to secondhand smoke (SHS).

METHODS

Mixed method study of first-year pediatric residents on one inpatient unit. Residents received training in smoking cessation counseling, nicotine replacement therapy (NRT) prescribing, and use of a CDS tool to aid in this process. The tool, which alerted when a patient was identified as exposed to SHS based on the history taken on admission or during a prior encounter, had the following capabilities: adding SHS exposure to the patient's problem list; referral to Free Quitline through discharge instructions; and linking to a printable NRT prescription form. We measured feasibility by EHR utilization data. We measured acceptability and usability of the tool by administering questionnaires to residents.

RESULTS

From June-August 2015, the alert triggered for 106 patients, and the tool was used for 52 (49%) patients. 41 (39%) patients had SHS exposure added to the problem list, 34 (32%) parents were referred to the Quitline through discharge instructions, and 15 (14%) parents were prescribed NRT. 10 out of 15 (67%) eligible pediatricians used the tool. All clinicians surveyed (9 out of 10) found the tool acceptable and rated its usability good to excellent (average System Usability Scale score was 85 out of 100, 95% CI, 76-93).

CONCLUSIONS

A non-interruptive CDS tool to help residents provide smoking cessation counseling in the hospital was feasible, acceptable, and usable. Future work will investigate impacts on patient outcomes.

Smoking Behavior and Healthcare Expenditure in the United States, 1992-2009: Panel Data Estimates

BACKGROUND

Reductions in smoking in Arizona and California have been shown to be associated with reduced per capita healthcare expenditures in these states compared to control populations in the rest of the US. This paper extends that analysis to all states and estimates changes in healthcare expenditure attributable to changes in aggregate measures of smoking behavior in all states.

METHODS AND FINDINGS

State per capita healthcare expenditure is modeled as a function of current smoking prevalence, mean cigarette consumption per smoker, other demographic and economic factors, and cross-sectional time trends using a fixed effects panel data regression on annual time series data for each the 50 states and the District of Columbia for the years 1992 through 2009. We found that 1% relative reductions in current smoking prevalence and mean packs smoked per current smoker are associated with 0.118% (standard error [SE] 0.0259%, p < 0.001) and 0.108% (SE 0.0253%, p < 0.001) reductions in per capita healthcare expenditure (elasticities). The results of this study are subject to the limitations of analysis of aggregate observational data, particularly that a study of this nature that uses aggregate data and a relatively small sample size cannot, by itself, establish a causal connection between smoking behavior and healthcare costs. Historical regional variations in smoking behavior (including those due to the effects of state tobacco control programs, smoking restrictions, and differences in taxation) are associated with substantial differences in per capita healthcare expenditures across the United States. Those regions (and the states in them) that have lower smoking have substantially lower medical costs. Likewise, those that have higher smoking have higher medical costs. Sensitivity analysis confirmed that these results are robust.

CONCLUSIONS

Changes in healthcare expenditure appear quickly after changes in smoking behavior. A 10% relative drop in smoking in every state is predicted to be followed by an expected $63 billion reduction (in 2012 US dollars) in healthcare expenditure the next year. State and national policies that reduce smoking should be part of short term healthcare cost containment.

Intravenous magnesium sulfate for treating children with acute asthma in the emergency department

BACKGROUND

Acute asthma in children can be life-threatening and must be treated promptly in the emergency setting. Intravenous magnesium sulfate is recommended by various guidelines for cases of acute asthma that have not responded to first-line treatment with bronchodilators and steroids. The treatment has recently been shown to reduce the need for hospital admission for adults compared with placebo, but it is unclear whether it is equally effective for children.

OBJECTIVES

To assess the safety and efficacy of intravenous magnesium sulfate (IV MgSO4) in children treated for acute asthma in the emergency department (ED).

SEARCH METHODS

We identified studies by searching the Cochrane Airways Review Group Specialised Register up to 23 February 2016. We also searched ClinicalTrials.gov and reference lists of other reviews, and we contacted study authors to ask for additional information.

SELECTION CRITERIA

We included randomised controlled trials of children treated in the ED for exacerbations of asthma if they compared any dose of IV MgSO4 with placebo.

DATA COLLECTION AND ANALYSIS

Two review authors screened the results of the search and independently extracted data from studies meeting the inclusion criteria. We resolved disagreements through discussion and contacted study authors in cases of missing data and other uncertainties relating to the studies.We analysed dichotomous data as odds ratios and continuous data as mean differences, both using fixed-effect models. We assessed each study for risk of bias and rated the quality of evidence for each outcome with GRADE and presented the results in a 'Summary of findings' table. There was insufficient evidence to conduct the planned subgroup analyses.

MAIN RESULTS

Five studies (182 children) met the inclusion criteria, and four contributed data to at least one meta-analysis. The included studies were overall at low risk of bias, but our confidence in the evidence was generally low, mainly due to the small sample sizes. Treatment with IV MgSO4 reduced the odds of admission to hospital by 68% (odds ratio (OR) 0.32, 95% confidence interval (CI) 0.14 to 0.74; children = 115; studies = 3; I(2) = 63%). This result was based on data from just three studies including 115 children. Meta-analysis for the secondary outcomes was extremely limited by paucity of data. We performed meta-analysis for the outcome 'return to the emergency department within 48 hours', which showed a very imprecise effect estimate that was not statistically significant (OR 0.40, 95% CI 0.02 to 10.30; children = 85; studies = 2; I(2) = 0%). Side effects and adverse events were not consistently reported and meta-analysis was not possible, however few side effects or adverse events were reported.

AUTHORS' CONCLUSIONS

IV MgSO4 may reduce the need for hospital admission in children presenting to the ED with moderate to severe exacerbations of asthma, but the evidence is extremely limited by the number and size of studies. Few side effects of the treatment were reported, but the data were extremely limited.

Legislative smoking bans for reducing harms from secondhand smoke exposure, smoking prevalence and tobacco consumption

BACKGROUND

Smoking bans have been implemented in a variety of settings, as well as being part of policy in many jurisdictions to protect the public and employees from the harmful effects of secondhand smoke (SHS). They also offer the potential to influence social norms and the smoking behaviour of those populations they affect. Since the first version of this review in 2010, more countries have introduced national smoking legislation banning indoor smoking.

OBJECTIVES

To assess the effects of legislative smoking bans on (1) morbidity and mortality from exposure to secondhand smoke, and (2) smoking prevalence and tobacco consumption.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register, MEDLINE, EMBASE, PsycINFO, CINAHL and reference lists of included studies. We also checked websites of various organisations. Date of most recent search; February 2015.

SELECTION CRITERIA

We considered studies that reported legislative smoking bans affecting populations. The minimum standard was having an indoor smoking ban explicitly in the study and a minimum of six months follow-up for measures of smoking behaviour. Our search included a broad range of research designs including: randomized controlled trials, quasi-experimental studies (i.e. non-randomized controlled studies), controlled before-and-after studies, interrupted time series as defined by the Cochrane Effective Practice and Organisation of Care Group, and uncontrolled pre- and post-ban data.

DATA COLLECTION AND ANALYSIS

One author extracted characteristics and content of the interventions, participants, outcomes and methods of the included studies and a second author checked the details. We extracted health and smoking behaviour outcomes. We did not attempt a meta-analysis due to the heterogeneity in design and content of the studies included. We evaluated the studies using qualitative narrative synthesis.

MAIN RESULTS

There are 77 studies included in this updated review. We retained 12 studies from the original review and identified 65 new studies. Evidence from 21 countries is provided in this update, an increase of eight countries from the original review. The nature of the intervention precludes randomized controlled trials. Thirty-six studies used an interrupted time series study design, 23 studies use a controlled before-and-after design and 18 studies are before-and-after studies with no control group; six of these studies use a cohort design. Seventy-two studies reported health outcomes, including cardiovascular (44), respiratory (21), and perinatal outcomes (7). Eleven studies reported national mortality rates for smoking-related diseases. A number of the studies report multiple health outcomes. There is consistent evidence of a positive impact of national smoking bans on improving cardiovascular health outcomes, and reducing mortality for associated smoking-related illnesses. Effects on respiratory and perinatal health were less consistent. We found 24 studies evaluating the impact of national smoke-free legislation on smoking behaviour. Evidence of an impact of legislative bans on smoking prevalence and tobacco consumption is inconsistent, with some studies not detecting additional long-term change in existing trends in prevalence.

AUTHORS' CONCLUSIONS

Since the first version of this review was published, the current evidence provides more robust support for the previous conclusions that the introduction of a legislative smoking ban does lead to improved health outcomes through reduction in SHS for countries and their populations. The clearest evidence is observed in reduced admissions for acute coronary syndrome. There is evidence of reduced mortality from smoking-related illnesses at a national level. There is inconsistent evidence of an impact on respiratory and perinatal health outcomes, and on smoking prevalence and tobacco consumption.

Second-hand smoke in four English prisons: an air quality monitoring study

Background

To measure levels of indoor pollution in relation to smoking in four English prisons.

Methods

TSI SidePak AM510 Personal Aerosol Monitors were used to measure concentrations of particulate matter less than 2.5 μm in diameter (PM_2.5) for periods of up to 9 h in selected smoking and non-smoking areas, and personal exposure monitoring of prison staff during a work shift, in four prisons.

Results

PM_2.5 data were collected for average periods of 6.5 h from 48 locations on 25 wing landings where smoking was permitted in cells, on 5 non-smoking wings, 13 prisoner cells, and personal monitoring of 22 staff members. Arithmetic mean PM_2.5 concentrations were significantly higher on smoking than non-smoking wing landings (43.9 μg/m³ and 5.9 μg/m³ respectively, p < 0.001) and in smoking than non-smoking cells (226.2 μg/m³ and 17.0 μg/m³ respectively, p < 0.001). Staff members wore monitors for an average of 4.18 h, during which they were exposed to arithmetic mean PM_2.5 concentration of 23.5 μg/m³.

Conclusions

The concentration of PM_2.5 pollution in smoking areas of prisons are extremely high. Smoking in prisons therefore represents a significant health hazard to prisoners and staff members.

Increased health service use for asthma, but decreased for COPD: Northumbrian hospital episodes, 2013-2014

The burden of respiratory disease has persisted over the years, for both men and women. The aim of the present study was to investigate the hospital episode rates in respiratory disease and to understand whether and how the use of the health service for respiratory disease might have changed in recent years in the North-East of England. Hospital episode data covering two full calendar years (in 2013–2014) was extracted from the Northumbria Healthcare NHS Foundation Trust, which serves a population of nearly half a million. Hospital episode rates were calculated from admissions divided by annual and small area-specific population size by sex and across age groups, presented with per 100,000 person-years. The use of the health service for influenza and pneumonia, acute lower respiratory infections and chronic obstructive pulmonary disease (COPD) increased with an advancing age, except for acute upper respiratory infections and asthma. Overall, the use of the health service for common respiratory diseases has seemed to be unchanged, except for asthma. There were large increases in young adults aged 20–50 for both men and women and the very old aged 90+ in women. Of note, there were large increases in acute lower respiratory infections for both men and women aged 90+, whereas there was also a large decrease in COPD in women aged 80–90. This is the first study to examine health service use for respiratory diseases by calculating the detailed population size as denominator. Re-diverting funding to improve population health on a yearly basis may serve the changing need in local areas.

Smoke-free legislation reduces hospital admissions for childhood lower respiratory tract infection

BACKGROUND

Previous studies showed reduction of hospital admissions for asthma after implementation of comprehensive smoke-free legislation. We aimed to evaluate the impact of comprehensive smoke-free legislation implemented in Hong Kong in 2007 on hospital admissions for childhood lower respiratory tract infection (LRTI).

METHODS

We obtained data on 75 870 hospital admissions for LRTI among children ≤18 years of age between January 2004 and December 2012 from all Hospital Authority hospitals. Using a negative binomial regression model, we assessed the impact of smoke-free legislation on admission counts.

RESULTS

After legislation implementation, there was an immediate effect with a change in the admission count of -33.5% (95% CI -36.4% to -30.5%), and a change in time trend to -13.9% per year (95% CI -16.0% to -11.7%). Overall, the legislation was associated with a net 47.4% reduction in admission counts in the first year. We estimated that the legislation was associated with a reduction of 13 635 admissions in the first 6 years after implementation. The immediate reduction and change in time trend was more apparent among school-age than preschool children.

CONCLUSIONS

Implementation of comprehensive smoke-free legislation was associated with a significant reduction in hospital admissions for childhood LRTI.

The Impact of Tobacco Smoke Exposure on Childhood Asthma in a Medicaid Managed Care Plan

BACKGROUND

Tobacco smoke exposure increases breathing problems of children. Texas Children's Health Plan is a Managed Medicaid and Children's Health Insurance Program (CHIP) managed care provider. The aim of this study is to determine associations among tobacco smoke exposure, asthma prevalence, and asthma health-care utilization.

METHODS

Texas Children's Health Plan conducts an annual survey of members who have a physician visit. Questions were added to the survey in March 2010 about asthma and tobacco smoke exposure. Survey results for children < 18 years of age were matched to health plan claims data for the 12 months following the date of the physician visit.

RESULTS

A total of 22,470 parents of unique members/patients from birth to < 18 years of age participated in the survey. More whites than African Americans or Hispanics report that the child's mother is a smoker (19.5% vs 9.1% and vs 2.3%, respectively; P < .001). Compared with children whose mother does not smoke, parent report of asthma diagnosis and claims for dispensing of short-acting beta agonist medication are greater if the mother is a smoker (adjusted OR, 1.20 [95% CI, 1.03-1.40] and 1.24 [95% CI, 1.08-1.42], respectively). In contrast to Medicaid, in which there are no out-of-pocket costs, the CHIP line of business requires copays for ED visits. ED visits are influenced by maternal smoking only in the CHIP line of business (adjusted OR, 4.40; 95% CI, 1.69-11.44).

CONCLUSION

Maternal smoking increases risk for asthma diagnosis and prescription of asthma quick relief medication. Maternal smoking predicted asthma-related ED visits only for the CHIP line of business.

Decline in admissions for childhood asthma, a 26-year period population-based study

BACKGROUND

The prevalence of childhood asthma has increased, although the rate of hospitalization for asthma seems to decrease. In Norway, the rate of hospital admission for childhood asthma from 1984 to 2000 increased. The aim of this study was to assess further trends in hospital admissions for childhood asthma up to 2010.

METHODS

A population-based study including children 1-13 yrs of age hospitalized for asthma during six periods from 1984/1985 to 2009/2010 in Rogaland, Norway, was performed. Medical records from 1536 admissions (1050 children) were studied; and gender, age, number of admissions, length of hospital stay, medications and symptoms were recorded.

RESULTS

For all age groups, the rate of admissions per 10.000 increased from 20.1 in 1984/85 to 33.7 in 1989/90, but declined to 14.4 in 2009/2010. Rates were highest in boys (OR 1.87; 95% CI: 1.69, 2.09), younger age groups (OR 2.51; 2.38, 2.64) and decreased from 1984 to 2010 (OR 0.92; 0.88, 0.94). The rates of readmissions were higher than for primary admissions (OR 1.33; 1.19, 1.47). From 1984 to 2010, there was an increased use of inhaled corticosteroids prior to admission (6 to 51%) and started at discharge (7 to 37%), and systemic steroids given during admission (19 to 83%).

CONCLUSION

There has been a substantial decline in the rate of hospital admissions for childhood asthma after 1989/1990, with major differences between age groups and genders. The decline could be due to improved care of children with asthma or a real reduction in asthma exacerbations.

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.

Protecting Children From Tobacco, Nicotine, and Tobacco Smoke

This technical report serves to provide the evidence base for the American Academy of Pediatrics' policy statements "Clinical Practice Policy to Protect Children From Tobacco, Nicotine, and Tobacco Smoke" and "Public Policy to Protect Children From Tobacco, Nicotine, and Tobacco Smoke." Tobacco use and involuntary exposure are major preventable causes of morbidity and premature mortality in adults and children. Tobacco dependence almost always starts in childhood or adolescence. Electronic nicotine delivery systems are rapidly gaining popularity among youth, and their significant harms are being documented. In utero tobacco smoke exposure, in addition to increasing the risk of preterm birth, low birth weight, stillbirth, placental abruption, and sudden infant death, has been found to increase the risk of obesity and neurodevelopmental disorders. Actions by pediatricians can help to reduce children's risk of developing tobacco dependence and reduce children's involuntary tobacco smoke exposure. Public policy actions to protect children from tobacco are essential to reduce the toll that the tobacco epidemic takes on our children.

Smoke-free legislation and the incidence of paediatric respiratory infections and wheezing/asthma: interrupted time series analyses in the four UK nations

We investigated the association between introduction of smoke-free legislation in the UK (March 2006 for Scotland, April 2007 for Wales and Northern Ireland, and July 2007 for England) and the incidence of respiratory diseases among children. We extracted monthly counts of new diagnoses of wheezing/asthma and RTIs among children aged 0–12 years from all general practices in the Clinical Practice Research Datalink during 1997–2012. Interrupted time series analyses were performed using generalised additive mixed models, adjusting for underlying incidence trends, population size changes, seasonal factors, and pandemic influenza, as appropriate. 366,642 new wheezing/asthma diagnoses and 4,324,789 RTIs were observed over 9,536,003 patient-years. There was no statistically significant change in the incidence of wheezing/asthma after introduction of smoke-free legislation in England (incidence rate ratio (IRR) 0.94, 95% CI 0.81–1.09) or any other UK country (Scotland: IRR 0.99, 95% CI 0.83–1.19; Wales: IRR 1.09, 95% CI 0.89–1.35; Northern Ireland: IRR 0.96, 95% CI 0.76–1.22). Similarly no statistically significant changes in RTI incidence were demonstrated (England: IRR 0.95, 95% CI 0.86–1.06; Scotland: IRR 0.96, 95% CI 0.83–1.11; Wales: IRR 0.97, 95% CI 0.86–1.09; Northern Ireland: IRR 0.90, 95% CI 0.79–1.03). There were no demonstrable reductions in the incidence of paediatric wheezing/asthma or RTIs following introduction of smoke-free legislation in the UK.