Impact of Electronic Cigarette use on Cardiovascular Health: Current Evidence, Causal Pathways, and Public Health Implications

Electronic cigarette (e-cigarette) use is increasing in Europe and the USA. While mounting evidence exists regarding an array of associated adverse health effects, to date limited evidence exists regarding the health effects of e-cigarette use on cardiovascular (CV) disease (CVD). The present review summarizes the effects of e-cigarette use on CV health. A search strategy of in vivo experimental, observational studies (including population-based cohort studies), and interventional studies was conducted in PubMed, MEDLINE, and Web of Science (April 1, 2009-April 1, 2022). The main findings revealed that the influence of e-cigarette on health are attributed mainly to the individual and interactive effects of flavors and additives used in e-cigarette fluids, along with the extended heating. The above collectively stimulate prolonged sympathoexcitatory CV autonomic effects, such as increased heart rate and diastolic blood pressure (BP), as well as decreased oxygen saturation. Hence, e-cigarette users are at increased risk of developing atherosclerosis, hypertension, arrhythmia, myocardial infarction, and heart failure. Such risks are anticipated to increase, especially among the young who are increasingly adopting e-cigarette use particularly with flavored additives. Further investigations are urgently needed to evaluate the long-term effects of e-cigarette use, particularly among susceptible population groups such as youth.

"Inhaling hazards, exhaling insights: a systematic review unveiling the silent health impacts of secondhand smoke pollution on children and adolescents

The health risks of smoking are widely known, but the impact of secondhand smoke on children and adolescents is often underestimated. Despite efforts to reduce smoking, exposure to secondhand smoke remains a significant public health concern, especially for young individuals. This systematic review aims to explore the health impacts of secondhand smoking on children and adolescents. Following PRISMA guidelines, 18 eligible studies from 8 countries published between 2015 and 2023 were identified through PubMed, SCOPUS, and Web of Science databases. Findings revealed that passive smoking is associated with respiratory issues like asthma and respiratory infections in children and adolescents aged 4 months to 18 years. Significant correlations were found between asthma severity and cotinine levels, a marker of passive smoking. Additionally, metabolic issues, cardiovascular effects, and ophthalmological changes, and alterations in neurocognitive functions, were noted. Urgent public health interventions are needed to reduce smoking prevalence and protect this vulnerable demographic.

Tobacco Smoke Exposure and Sleep Duration among U.S. Adolescents

OBJECTIVES

Tobacco smoke exposure (TSE) and poor sleep are public health problems with their own set of consequences. This study assessed whether TSE was associated with sleep duration among U.S. adolescents.

METHOD

We conducted a secondary analysis of 2013-2018 National Health and Nutrition Examination Survey data including 914 nontobacco-using adolescents ages 16-19 years. TSE measures included cotinine and self-reported home TSE groups including no home TSE, thirdhand smoke (THS) exposure, and secondhand smoke (SHS)+THS exposure. Sleep duration was assessed in hours and categorically as insufficient sleep (recommended hours). Weighted multiple linear regression and multinomial regression models were conducted.

RESULTS

Adolescents with higher log-cotinine levels had higher number of sleep hours (β = 0.31, 95%CI = 0.02,0.60) and were at increased odds of reporting excess sleep (AOR = 1.41, 95%CI = 1.40,1.42), but were at reduced odds of reporting insufficient sleep (AOR = 0.88, 95%CI = 0.87,0.89). Compared to adolescents with no home TSE, adolescents with home THS exposure and home SHS+THS exposure were at increased odds of reporting insufficient sleep (AOR = 2.27, 95%CI = 2.26,2.29; AOR = 2.75, 95%CI = 2.72,2.77, respectively) and excess sleep (AOR = 1.89, 95%CI = 1.87,1.90; AOR = 5.29, 95%CI = 5.23,5.34, respectively).

CONCLUSIONS

TSE may affect insufficient and excess sleep duration among adolescents. Eliminating TSE may promote adolescent respiratory and sleep health.

Impacts of environmental tobacco smoke on the onset and progression of multiple sclerosis: a systematic review

BACKGROUND

 Unlike cigarette smoking, environmental tobacco smoke (ETS) has not been as well described as an environmental risk for Multiple sclerosis (MS) nor as a risk factor for disease progression.

OBJECTIVE

 We systematically reviewed the association between ETS and the risk of onset and/or progression of MS.

METHODS

 We systematically screened MedLine/PubMed, Science Direct, LILACs, and SciELO searching for publications between January 1st, 2010, and July 5, 2021, with the following keywords: "multiple sclerosis and smoking"; "multiple sclerosis and passive smoking"; "multiple sclerosis and secondhand smoking".

RESULTS

 Fifteen articles were included in this review, which consisted of systematic reviews with meta-analysis (N = 2), systematic reviews (N = 2), and observational studies (N = 11). Both meta-analyses reported an impact of ETS on MS onset among secondhand smokers. One of the systematic reviews selected two observational studies showing the association between ETS and MS development, and one study that did not find a significant association between ETS and the risk of MS development. The other systematic review identified selected eight articles showing a relationship between ETS and MS. Seven observational studies reported higher odds of MS onset when associated with ETS. Four observational studies did not show a relationship between ETS and MS onset or progression.

CONCLUSION

 Most articles showed a positive association between ETS exposure and the risk of developing MS. On the other hand, an association between ETS and a higher risk for MS progression could not be established.

Extent of smoking at a Danish hospital with a smoke-free policy

AIM

One-fifth of the Danish population smoke and exposure to second-hand smoke has well-documented adverse health effects. The smoking policy at hospital level prohibits hospital staff from smoking on the hospital grounds while patients and visitors may smoke in outdoor smoking cabins. This study aimed to quantify smoking at a Danish hospital and document any policy breaches.

METHODS

In April 2020, we collected cigarette butts and observed smokers at the outdoor grounds to document smoking behaviour.

RESULTS

In total, 7152 cigarette butts were collected during one week and 368 people were observed smoking at the outdoor grounds during four observation days. Of all collected cigarette butts, 55% were collected outside the smoking cabins and 62% of all smokers were observed smoking outside the smoking cabins. In addition, 31 staff were observed smoking.

CONCLUSIONS

This study documents that smoking is prevalent at a smoke-free hospital and that the smoking policy is frequently violated. The frequency of smoking outside the cabins may at least partly be influenced by the COVID-19 pandemic. Smoking at a hospital can expose patients, visitors and staff to second-hand smoke with subsequent adverse health effects. Hospitals could play an exemplary role towards a smoke-free society (and not the exception), but the opportunity is not always seized.

Associations of childhood and current secondhand smoke exposure at home with current secondhand smoke exposure at work: A cross-sectional analysis of the Singapore multi-ethnic cohort

INTRODUCTION

Relationships between secondhand smoke exposure (SHSE) in various temporal and physical settings are not fully studied despite its adverse impacts on human health, especially in multi-ethnic Asian populations. We investigated associations of childhood and current SHSE at home (SHSEhome) with current SHSE at work (SHSEwork) in Singapore and its relation to sources of daily smokers at home.

METHODS

This cross-sectional study identified 925 healthy, never smoker working adults from the Singapore Multi-Ethnic Cohort (2004-2010). Firstly, the multiple logistic regression model estimated the adjusted odds ratios (AORs) of SHSEhome. Subsequently, sources of daily smokers entered through an additional model building process using the former as a base.

RESULTS

Current adults (AOR=2.05; 95% CI: 1.28-3.29) and childhood SHSEhome (AOR=1.43; 95% CI: 0.93-2.19) had a positive and no association with current SHSEwork, respectively. These findings persisted when smoker identity-related variables entered the model: child (AOR=3.56; 95% CI: 1.19-10.64) for current daily smokers; father (AOR=2.30; 95% CI: 0.94-5.64) and sibling (AOR=2.97; 95% CI: 1.55-5.68) for childhood. Compared to no childhood SHSEhome, only those living with their fathers and siblings who smoked daily at home had significantly higher odds of reporting current SHSEwork (AOR=3.70; 95% CI: 1.88-7.30).

CONCLUSIONS

Current SHSEhome was a risk factor for current SHSEwork, with risks elevated among those who smoke daily at home and living with their children. Childhood SHSEhome becomes a risk factor when daily household smokers include fathers and siblings. Deformalizing smoking could consider interpersonal dynamics of daily smokers at home with family members in different temporal settings, to reduce SHSEwork.

Tobacco Smoke Exposure and Gastrointestinal Problems Among US Children

This study examined the association between home tobacco smoke exposure (TSE) status and gastrointestinal problems in the past 12 months among US children. We conducted a secondary analysis of the 2018-2019 National Survey of Children's Health cross-sectional data including 20 149 children aged 4 to 10 years. Weighted logistic regression models unadjusted and adjusted for child and family covariates were fitted. Overall, 12.3% of children had home thirdhand smoke (THS) exposure only and 1.8% had home secondhand smoke (SHS) and THS exposure. Unadjusted (odds ratio [OR] = 1.70, 95% confidence interval [CI] = 1.32-2.20) and adjusted (adjusted odds ratio [AOR] = 1.51, 95% CI = 1.14-1.99) logistic regression results indicated that relative to children with no home TSE, children with home THS exposure only were at increased odds of having frequent or chronic difficulty with gastrointestinal problems over the past 12 months. Interventions are critically needed to promote smoking cessation among household members who live with children in order to reduce levels of SHS and THS in their homes.

Smoking and environmental tobacco smoke exposure: implications in ocular disorders

PURPOSE

This article aims to gather and review the available knowledge on several implications of smoking and environmental tobacco smoke (ETS) exposure in ocular disorders and provides pathomechanistic insights where applicable.

MATERIALS AND METHODS

PubMed and Scopus databases were searched for relevant studies on the association of smoking and ETS exposure with various ocular disorders. Studies with different evidence levels, e.g., in-vivo, case-control, cohort, and meta-analysis, were included.

RESULTS

Smoking is an established, modifiable risk factor in several ocular diseases, including cataract, age-related macular degeneration, and Graves' ophthalmopathy; smokers are subject to more severe disease courses and less favorable treatment outcomes. Uveitis is twice as likely in smokers; smoking may also delay its resolution. Smoking and ETS exposure are major risk factors for diseases of other organs, with associated ocular complications as well, such as diabetes mellitus. ETS exposure is also associated with ocular surface pathologies, including dry eye syndrome. In children, early-life ETS exposure and maternal smoking during pregnancy are strongly associated with refractive errors and strabismus. Currently, available data on potential risks attributable to ETS exposure regarding ocular diseases are scarce and, in some instances, controversial.

CONCLUSION

In addition to smoking, ETS exposure is also a significant public health concern with possible links to several ocular diseases. However, the level of education of at-risk populations in this regard does not match the strength of the evidence.

Decrease in Secondhand Smoke Exposure in Work and Public Places among Adults in the Philippines: An Analysis of the Global Adult Tobacco Survey, 2009 and 2015

The implementation of several tobacco control policies in the Philippines may have contributed to a decrease in secondhand smoke (SHS) exposure. We examined changes in SHS exposure at work and in public places between 2009 and 2015 among adults aged ≥15 years and interpreted these results within the tobacco policy landscape in the Philippines. We analyzed the Philippines Global Adult Tobacco Survey 2009 and 2015 data. We examined marginal effects in logistic regression to get the adjusted prevalence of SHS exposure at five work and public places, controlling for selected characteristics. We calculated adjusted prevalence ratios and adjusted prevalence differences between 2009 and 2015. Adjusted prevalence of SHS exposure decreased from 2009 to 2015 by 19% (5.7 percentage points) at work, 45% (11.2 percentage points) in government buildings, 48% (3.2 percentage points) in healthcare facilities, 29% (8.2 percentage points) in restaurants, and 33% (19.9 percentage points) on public transportation. Although the prevalence of SHS exposure at work and in public places decreased significantly between 2009 and 2015, a substantial proportion of adults remain exposed to SHS. This study highlights the importance of continued implementation, enforcement, monitoring, and evaluation of tobacco control and prevention measures in the Philippines.

Smoking Behavior and Cigarette Expenditure in a Household: Evidence for Smoke-Free Houses Initiation in Indonesia

Background

The household is considered as a private area that is untouched tobacco control policies in developing countries, especially in Indonesia, which has not ratified the Framework Convention on Tobacco Control (FCTC) treaty.

Objectives

This study aims to identify smoking behavior and expenditure on cigarettes in the household, which are part of the initiation of a policy including a smoke-free home, so it assumes that the home is a public domain in Tegal Regency, Central Java Province, Indonesia.

Methods

This research is an observational study with a quantitative descriptive design. A total of 225 subjects in the seven regions designated as smoke-free areas were all selected as samples in this study and were willing to be the subject of research.

Results

The results found that 76.1% of smokers smoked with their nuclear family (wife/children/husband) present. Smoking behavior with the nuclear family inside the home (39.13%) and outside the home (36.96%) was more common than not smoking with the nuclear family. Expenditure for cigarettes per month was one-third of household revenue (IDR 607,521.74) based on the regency minimum wage (UMR) set by the local government.

Conclusions

The study concludes that smokers who smoke with family still lack knowledge on smoking's impact on health and household economics. The smoke-free regulation that is initiated should include households as a parameter.

Tobacco Smoke Exposure, School Engagement, School Success, and Afterschool Activity Participation Among US Children

BACKGROUND

Tobacco smoke exposure (TSE), defined as secondhand smoke (SHS) and thirdhand smoke (THS), is associated with negative health consequences. This study's objective was to assess the associations between home TSE status and school engagement, school success, and afterschool activity participation among school-aged children.

METHODS

We conducted a secondary analysis of 2018-2019 National Survey of Children's Health cross-sectional data. Children ages 6-11 years (N = 17,466) were categorized into home TSE groups: no home TSE; THS exposure only; and SHS and THS exposure. Weighted logistic and Poisson regression models were built.

RESULTS

Compared to children with no home TSE, children with home THS exposure only and SHS and THS exposure were at decreased odds of being engaged in school (AOR = 0.69, 95%CI = 0.57, 0.83; AOR = 0.63, 95%CI = 0.41, 0.97, respectively), and at increased odds of having ≥1 school-to-home contact about child problems in school (AOR = 1.83, 95%CI = 1.50, 2.23; AOR = 1.58, 95%CI = 1.05, 2.37, respectively). Children with THS exposure only were at increased odds of missing ≥1 school day (AOR = 1.43, 95%CI = 1.13, 1.81). Children with THS exposure only (ARR = 0.90, 95%CI = 0.83, 0.96) and SHS and THS exposure (ARR = 0.74, 95%CI = 0.61, 0.89) were at reduced likelihood of participating in a higher number of afterschool activities.

CONCLUSIONS

Children exposed to home tobacco smoke are at unique risk for poorer school engagement and success.

Prevalence and determinants of second-hand tobacco smoking in Pakistan

Background

Exposure to second-hand tobacco smoke is a public health problem in countries with high prevalence of active smoking such as Pakistan. However, few studies have assessed the prevalence and risk factors for exposure to second-hand tobacco smoke.

Aims

To estimate the prevalence and factors associated with exposure to second-hand tobacco smoke in Pakistan.

Methods

This study used data from the 2017-2018 Pakistan Demographic and Health Survey to calculate the prevalence and determinants of second-hand tobacco smoke exposure. Sociodemographic characteristics, family size and exposure to media by the respondents were the independent variables. The chi-square test and logistic regression analyses were used to evaluate the relationship between exposure to second-hand tobacco smoke and the independent variables.hy9.

Results

The survey included 61 940 adults, of which 30 027 (48.5%) were males and 31 913 (51.5%) females. The overall prevalence of exposure to second-hand tobacco smoke was 34.3%: 35.6% among males and 33.2% among females. Higher education level and rural residence were significantly positively associated with exposure to second-hand tobacco smoke among both sexes. Having a radio was inversely associated with exposure while having a television was positively associated with exposure among both sexes. Large family size was inversely associated with exposure. Currently and previously married females had significantly greater risk of exposure than never-married females.

Conclusion

Tailored health interventions and policies are needed that target populations at high-risk of exposure to second-hand tobacco smoke. Strict smoking bans in public places should be implemented to limit exposure to second-hand tobacco smoke in Pakistan.

Solid Fuel, Secondhand Smoke, and Lung Cancer Mortality: A Prospective Cohort of 323,794 Chinese Never-Smokers

Rationale: Household air pollution and secondhand tobacco smoke are known carcinogens for lung cancer, but large-scale estimates of the relationship with lung cancer mortality are lacking. Objectives: Using the large-scale cohort China Kadoorie Biobank, we prospectively investigated associations between these two risk factors and lung cancer death among never-smokers. Methods: The Biobank recruited 512,715 adults aged 30-79 years from 10 regions in China during 2004-2008. Self-reported never-smoking participants were followed up to December 31, 2016, with linkage to mortality data. Total duration of exposure to household air pollution was calculated from self-reported domestic solid fuel use. Exposure to secondhand tobacco smoke was ascertained using exposure at home and/or other places. Hazard ratios and 95% confidence intervals for associations between these two exposures and lung cancer death were estimated using Cox regression, adjusting for key confounders. Measurements and Main Results: There were 979 lung cancer deaths among 323,794 never-smoking participants without a previous cancer diagnosis during 10.2 years of follow-up. There was a log-linear positive association between exposure to household air pollution and lung cancer death, with a 4% increased risk per 5-year increment of exposure (hazard ratio = 1.04; 95% confidence interval = 1.01-1.06; P trend = 0.0034), and participants with 40.1-50.0 years of exposure had the highest risk compared with the never-exposed (hazard ratio = 1.53; 95% confidence interval = 1.13-2.07). The association was largely consistent across various subgroups. No significant association was found between secondhand smoke and lung cancer death. Conclusions: This cohort study provides new prospective evidence suggesting that domestic solid fuel use is associated with lung cancer death among never-smokers.

Tobacco Use and Exposure to Environmental Tobacco Smoke amongst Pregnant Women in the United Arab Emirates: The Mutaba'ah Study

Self-reported tobacco use is high in the male adult Emirati population (males ~36% vs. females ~3%); however, there are minimal data on tobacco use or exposure to environmental tobacco smoke (ETS) during pregnancy in the United Arab Emirates (UAE). This study investigated the prevalence of, and factors associated with, tobacco use and exposure to environmental tobacco smoke (ETS) amongst pregnant women in the UAE. Baseline cross-sectional data were analysed from the Mutaba’ah Study. Expectant mothers completed a self-administered questionnaire collecting sociodemographic information, maternal tobacco use, and ETS exposure during antenatal visits at three hospitals in Al Ain (UAE; May 2017–February 2021). Amongst 8586 women included in the study, self-reported tobacco use during pregnancy was low (0.7%), paternal tobacco use was high (37.9%), and a third (34.8%) of expectant mothers were exposed to ETS (28.0% at home only). Pregnant women who were employed (adjusted odds ratio (aOR): 1.35, 95% confidence interval (CI): 1.19–1.52), with childbirth anxiety (aOR 1.21, 95% CI 1.08–1.36), and with an increased number of adults living in the same household (aOR 1.02 95% CI 1.01–1.03) were independently more likely to be exposed to ETS. Pregnant women with higher education levels (aOR 0.84, 95% CI 0.75–0.94) and higher gravidity (aOR 0.95, 95% CI 0.92–0.99) were less likely to be exposed to ETS. Public health efforts targeting smoking cessation amongst husbands and promoting smoke-free homes are warranted to help reduce prenatal ETS exposure in the UAE.

Passive smoking may be associated with bleeding of cerebral arteriovenous malformation in non-smoking women: a retrospective analysis

BACKGROUND

Smoking has been considered to be a risk factor for cardiovascular disease, cancer, depression and other diseases in previous reports, and active smoking is considered to be a risk factor for hemorrhagic stroke. In addition, a retrospective study showed that male smokers were at increased risk of bleeding from arteriovenous malformation (AVM), compared with non-smokers. However, the effect of passive smoking on rupturing of cerebral AVM in non-smoking women has not been addressed.

OBJECTIVE

This study aimed to assess the impact of tobacco exposure on AVM bleeding risk in non-smoking women.

METHODS

A total of 393 non-smoking women diagnosed with AVM were included. They were divided into a bleeding group (205 women) and a non-bleeding group (188 women). We conducted univariate and multivariate analysis on these two groups. In univariate analysis, risk factors that might be related to AVM bleeding were analyzed. In multivariate analysis, the relationship between passive smoking and AVM rupture was analyzed by correcting confounding factors.

RESULTS

Multivariate analysis showed that the proportion of passive smoking was statistically different between the bleeding group and the non-bleeding group (OR = 1.609; CI = 1.031-2.509; p = 0.036).

CONCLUSION

Passive smoking may increase the risk of AVM bleeding in non-smoking women. This increased risk may be related to the inflammatory response, vascular wall damage, hemodynamic disorders, changes in atherosclerosis and changes in gene expression caused by passive smoking.

Secondhand Smoke in the Workplace Is Associated With Depression in Korean Workers

Background

Smoking negatively affects health, and previous studies argue that secondhand smoke (SHS) has a significantly negative health effect. We investigated whether SHS in the workplace influences workers' depression.

Methods

Three years of data (2014, 2016, and 2018) from the Korean National Health and Nutrition Examination Survey were analyzed. Participants who were not current smokers were classified into the occupational SHS exposed and non-exposed groups. Multivariate logistic regression was performed to estimate odds ratios (ORs) and 95% confidence intervals (CIs) by adjusting various covariates. Stratified analysis with variables, such as year, sex, occupational classification, average working hours, was additionally performed.

Results

The crude ORs of depression was 1.51 (95% CI: 1.27–1.80), and the fully adjusted OR with all the covariates was 1.57 (95% CI: 1.30–1.88). This indicated a significant relationship between occupational SHS and depression. The ORs increased every 2 years: 1.07 (95% CI: 0.79–1.44) in 2014, 1.88 (95% CI: 1.34–2.64) in 2016, and 2.07 (95% CI: 1.43–2.99) in year 2018. Stratification analysis also showed a significant association between SHS and depression among those in the prolonged work hours group and male employees, as well as blue- and white-collar workers.

Conclusion

SHS in the workplace was significantly associated with workers' depression. Our study provides insights into the impact of exposure to SHS for workers and provides a basis for further research and policy-making in this field.

Trends in premature mortality rates among the Polish population due to cardiovascular diseases

OBJECTIVES

At the end of the 20th century, after years of negligence in the prevention of cardiovascular diseases, Poland was struggling with very high premature mortality. The period of 1991-2005 brought significant improvements since the general public introduced beneficial dietary modifications. This paper aims to analyze the changes in the rate of premature mortality due to tobacco-dependent cardiovascular diseases in Poland in 2008-2017.

MATERIAL AND METHODS

The time trends of deaths occurring under the age of 65 years caused by ischemic heart disease, cerebrovascular disease, atherosclerosis and aortic aneurysm were analyzed. Both standardized and crude premature mortality rates were used, as well as mortality rates for patients grouped into 5-year age ranges with a breakdown by gender. The joinpoint model was used to determine these time trends.

RESULTS

Premature mortality due to the analyzed cardiovascular diseases decreased linearly in 2008-2017. In the case of ischemic heart disease and cerebrovascular diseases, the decrease amounted to approx. 5% per year, both in the female and male population. However, in the case of atherosclerosis and aortic aneurysms, the rate of mortality reduction ranged 4-7% per year. The reduction concerned all the examined age groups, but with different dynamics. The most considerable annual decrease was observed in the group of patients aged 40-44 years (7.9% for females and 8.9% for males). Along with the increase in age, the dynamics of reduction decreased.

CONCLUSIONS

In 2008-2017, Poland experienced a decline in premature mortality due to tobacco-related cardiovascular diseases, particularly in the age group of 40-44 years. The decline may have been associated, among other things, with a reduction in exposure to tobacco smoke, one of the cardiovascular risk factors. Int J Occup Med Environ Health. 2022;35(1):27-38.

Factors related to caregivers' risk perception of secondhand smoke exposure on children's health

INTRODUCTION

Home is one of the main places for children’s secondhand smoke (SHS) exposure. The implementation of smoke-free rules at home might be influenced by caregivers’ risk perception of SHS exposure. This study aimed to analyze factors related to caregivers’ risk perception of SHS exposure in children.

METHODS

We conducted a cross-sectional telephone survey among a representative sample of 2411 parents or legal guardians of children aged <12 years in Spain in 2016. The main study variable was caregivers’ healthrisk perception of SHS exposure on children. We investigated correlates of risk perception using multivariate Poisson regression models with robust variance.

RESULTS

Overall, 59.6% reported SHS exposure negatively affects children’s health a lot, while 34.1% that it affects quite a bit, and 5.5% and 0.8% a little bit or not at all, respectively. The factors associated with a higher caregivers’ risk perception were high education level (adjusted prevalence ratio, APR=1.11; 95% CI: 1.01–1.24), living in a non-smoking family unit (APR=1.17; 95% CI: 1.07–1.27), in a home with smoke-free rules (APR=1.34; 95% CI: 1.19–1.51), and with girls only (APR=1.14; 95% CI: 1.06–1.22).

CONCLUSIONS

Caregivers’ risk perception of SHS exposure is influenced by social determinants and smoking habits in family units. These findings support the need for interventions with a social equity perspective to reduce children’s SHS exposure.

Family Health Behavior: Preventive Measures against Acute Respiratory Infections in Under-5 Children

BACKGROUND

The under-5 mortality rate in Indonesia is 32 per 1,000 live births, still higher than the SDG target. Acute respiratory infections (ARIs), as one of the leading causes of death, must be prevented. Arguments emerge concerning the association of home crowding, health behavior, and the incidence of ARI.

METHODS

A cross-section analysis with the Indonesia Demographic and Health Survey (IDHS) 2017 dataset is performed. Samples are restricted to 16,555 children aged 0-59 months who lived with their mother (eligible women interviewed) during the survey. For each of the variables observed during this study, missing data must be omitted as exclusion criteria. A 100 per cent answer rate was achieved. Logistic regression was used to determine ARI-associated factors, by examining the effect of each explanatory factor (independent variables) on the odds ratio of ARI (one dependent binary variable).

RESULTS

The prevalence of ARI was more common among children living in the poorest households (AOR 1.66; 95% CI, 1.20 - 2.28) and those exposed to indoor tobacco smoke pollution (AOR 1.27; 95% CI, 1.04-1.56). On the other hand, those aged 0-5 months (AOR 0.59; 95% CI, 0.43-0.82), living at home with improved sanitation (AOR 0.74; 95% CI, 0.61-0.89), and exclusively breastfed (AOR 0.85; 95% CI, 0.73-0.99) were less likely to have ARI.

CONCLUSIONS

Home crowding is not associated with ARI. Efforts should be focused on preserving family health behavior. The family functioned as a health-support system for their under-5 children by establishing an indoor tobacco smoking-free zone, practicing exclusive breastfeeding, and enhancing hygiene facilities.

Assessing public support for extending smoke-free policies beyond enclosed public places and workplaces: protocol for a systematic review and meta-analysis

INTRODUCTION

Smoke-free enclosed public environments are effective in reducing exposure to secondhand smoke and yield major public health benefits. Building on this, many countries are now implementing smoke-free policies regulating smoking beyond enclosed public places and workplaces. In order to successfully implement such 'novel smoke-free policies', public support is essential. We aim to provide the first comprehensive systematic review and meta-analysis assessing levels and determinants of public support for novel smoke-free policies.

METHODS AND ANALYSIS

The primary objective of this review is to summarise the level of public support for novel smoke-free policies. Eight online databases (Embase.com, Medline ALL Ovid, Web of Science Core Collection, WHO Library Database, Latin American and Caribbean Health Sciences Literature, Scientific Online Library Online, PsychINFO and Google Scholar) will be searched from 1 January 2004 by two independent researchers with no language restrictions. The initial search was performed on 15 April 2020 and will be updated prior to finalisation of the report. Studies are eligible if assessing support for novel smoke-free policies in the general population (age ≥16 years) and have a sample size of n≥400. Studies funded by the tobacco industry or evaluating support among groups with vested interest are excluded. The primary outcome is proportion of public support for smoke-free policies, subdivided according to the spaces covered: (1) indoor private spaces (eg, cars) (2) indoor semiprivate spaces (eg, multi-unit housing) (3) outdoor (semi)private spaces (eg, courtyards) (4) non-hospitality outdoor public spaces (eg, parks, hospital grounds, playgrounds) and (5) hospitality outdoor public spaces (eg, restaurant terraces). The secondary objective is to identify determinants associated with public support on three levels: (1) within-study determinants (eg, smoking status) (2) between-study determinants (eg, survey year) and (3) context-specific determinants (eg, social norms). Risk of bias will be assessed using the Mixed Methods Appraisal Tool and a sensitivity analysis will be performed excluding studies at high risk of bias.

ETHICS AND DISSEMINATION

No formal ethical approval is required. Findings will be disseminated to academics, policymakers and the general public.

Addressing Environmental Smoke Exposure During Pediatric Hospitalization: Attitudes and Practices of Pediatric Nurses Versus Respiratory Therapists

BACKGROUND

Tobacco smoke exposure leads to numerous adverse health effects in children. Providing cessation interventions to caregivers who smoke during pediatric hospitalizations can help protect children from such exposure. Both pediatric registered nurses (RNs) and pediatric respiratory therapists (RTs) are well positioned to provide these interventions. Little is known about their rates of participation in cessation efforts. Our objective was to compare the attitudes and practice of pediatric RNs versus pediatric RTs to evaluate their relative cessation-intervention practices in the in-patient pediatric setting.

METHODS

An online survey was sent to pediatric RNs and RTs at 4 tertiary pediatric hospitals in California. The survey assessed individual demographics, work environment, experience, beliefs, and practices related to smoking cessation activities. Questions used 3-point and 5-point Likert scales and were compared with the chi-square test. Institutions with a response rate < 20% were excluded.

RESULTS

A total of 401 respondents were included in the final analysis (292 RNs, 109 RTs). RTs versus RNs were older (42.0 y vs 35.4 y, respectively, P < .001) and more likely to be former smokers (29.9% vs 13.3%, respectively, P < .001). RNs reported lower levels of confidence in discussing smoking cessation with parents, with 11.7% saying they felt "very confident" compared to 29.0% of RTs (P < .001). RNs also reported screening for smoke exposure less frequently than RTs, with 18.8% responding "often" or "always" compared to 28.9% of RTs (P = .033). RNs had lower rates of advising parents "to make a smoke-free home policy" compared to RTs (ie, 13.4% vs 26.9%, respectively, P = .002).

CONCLUSIONS

Compared to in-patient pediatric RNs, RTs reported higher rates of confidence in providing cessation interventions, screening for smoke exposure, and counseling on reducing smoke exposure, suggesting that they may be better positioned for intervening. These results can inform the design of an in-patient cessation intervention for caregivers of hospitalized children.

Hospital entrance smoking is reduced by broadcasting recorded antitobacco messages from Australian primary school children over entrance public address system

ISSUE ADDRESSED

Smoking near hospital entrances occurs frequently despite smoke-free policies, resulting in multiple issues including second-hand smoke exposure (SHS) to vulnerable populations. Primary school children were engaged through their health curriculum to produce antismoking audio recordings for broadcast over a hospital entrance loudspeaker system to determine if this reduced smoking.

METHOD

Students produced original recordings against hospital grounds smoking during class workshops, from which a collection (n = 16) was selected. Episodes of entrance smoking and total entrance traffic were recorded using security camera infrastructure over a 5-week period. A computer-controlled entrance loudspeaker played a message which was followed by silence until a new (different) message was played. Intensity of messaging was moderate in week 3 (every 5 minutes), increasing to high in week 4 (3 minutely) and compared to no messages (weeks 1-2 preintervention) and week 5 (postintervention).

RESULTS

Smokers presented 316 times, smoking 523 cigarettes over 155 hours of observation (patients 70.6%, visitors 29.4%). SHS exposure was high given 172 others used the entrance/hour. Smoking was highest in the preintervention period (weeks 1-2), median five cigarettes/hr [IQR,3-7 (min = 0, max = 12)], falling to four cigarettes/hr during 5-minutely broadcasts [IQR,2-5 (min = 1, max = 14)] (P = .06), but zero cigarettes/hr during 3-minutely broadcasts [IQR,0-1(min = 0, max = 7)] (P < .0001). Postintervention (no broadcasts), smoking increased from zero to 1 cigarette/hr [IQR,0-3 (min = 0, max = 5)]; (P = .052). Nonsmoker movements did not change significantly between each period.

CONCLUSION

Intensive (3 minutely) broadcasting of short antismoking messages significantly reduced hospital entrance smoking. SO WHAT?: Health services can positively interact with the health curriculum of primary schools against tobacco use while developing low-cost strategies to effectively deter entrance smoking.

Systematic Review of Behaviour Change Techniques within Interventions to Reduce Environmental Tobacco Smoke Exposure for Children

Children are particularly vulnerable to environmental tobacco smoke (ETS). There is no routine support to reduce ETS in the home. We systematically reviewed trials to reduce ETS in children in order to identify intervention characteristics and behaviour change techniques (BCTs) to inform future interventions. We searched Medline, EMBASE, CINAHL, PsycINFO, ERIC, Cochrane Central Register of Controlled Trials, and Cochrane Tobacco Addiction Group Specialised Register from January 2017 to June 2020 to update an existing systematic review. We included controlled trials to reduce parent/caregiver smoking or ETS in children <12 years that demonstrated a statistically significant benefit, in comparison to less intensive interventions or usual care. We extracted trial characteristics; and BCTs using Behaviour Change Technique Taxonomy v1. We defined "promising" BCTs as those present in at least 25% of effective interventions. Data synthesis was narrative. We included 16 trials, of which eight were at low risk of bias. All trials used counselling in combination with self-help or other supporting materials. We identified 13 "promising" BCTs centred on education, setting goals and planning, or support to reach goals. Interventions to reduce ETS in children should incorporate effective BCTs and consider counselling and self-help as mechanisms of delivery.

Supporting Parents Living in Disadvantaged Areas of Edinburgh to Create a Smoke-Free Home Using Nicotine Replacement Therapy (NRT): A Two-Phase Qualitative Study

Exposure to second-hand smoke (SHS) in the home is largely associated with socio-economic disadvantage. Disadvantaged parents face specific challenges creating a smoke-free home, often caring for children in accommodation without access to outdoor garden space. Existing smoke-free home interventions largely fail to accommodate these constraints. Innovative approaches are required to address this inequality. In this two-phase study, we engaged with parents living in disadvantaged areas of Edinburgh, Scotland, to explore tailored approaches to creating a smoke-free home and develop and pilot-test an intervention based on their views and preferences. In Phase 1, qualitative interviews with 17 parents recruited from Early Years Centres explored alternative approaches to smoke-free home interventions. In Phase 2, an intervention based on parents’ views and preferences was pilot-tested with parents recruited through Early Years and Family Nurse Partnership centres. Seventeen parents took part in an interview to share their views/experiences of the intervention. Data from both study phases were thematically analysed. Phase 1 findings suggested that parents associated nicotine replacement therapy (NRT) with quit attempts but supported the idea of NRT use for temporary abstinence to create a smoke-free home, viewing this as a safer option than using e-cigarettes indoors. In Phase 2, 54 parents expressed an interest in accessing NRT to create a smoke-free home, 32 discussed NRT product choice during a home visit from a smoking adviser, and 20 collected their free NRT prescription from the pharmacy. NRT was used for up to 12 weeks in the home, with ongoing advice available from pharmacy staff. During qualitative interviews (n = 17), parents self-reported successfully creating a smoke-free home, quitting smoking, and reduced cigarette consumption, often exceeding their expectations regarding changes made. The intervention was acceptable to parents, but the multi-step process used to access NRT was cumbersome. Some participants were lost to this process. Parents living in disadvantaged circumstances may benefit from access to NRT for temporary abstinence in the home to assist them to protect their children from SHS exposure. Further research using a more streamlined approach to NRT access is required to determine the feasibility and cost-effectiveness of this approach.

[Correlates of secondhand smoke exposure in public and private settings in Mexico. Encodat 2016.]

OBJECTIVE

To assess the correlates of secondhand smoke exposure (SHS) in public and private settings.

MATERIALS AND METHODS

Data came from the 2016 National Survey of Drug, Alcohol and Tobacco use. Multilevel Poisson models were conducted to evaluate factors associated with SHS.

RESULTS

Having a higher education, being male and being a young adult were associated with higher SHS in bars and restaurants. Men had greater SHS at work, while women and adolescents had greater exposure at home. Adults older than 45 years had higher SHS on public transportation compared to adolescents between 12-17 years old.

CONCLUSIONS

Exposure to SHS remains high and affects the population differentially. To reduce SHS, it is necessary to apply Article 8 of the Framework Convention on Tobacco Control.

Prevalence and factors related to second hand smoking exposure, knowledge and response among adolescents in rural Puducherry

OBJECTIVES

To determine the prevalence of Second Hand Smoking (SHS) and assess the factors related to exposure, knowledge and response to SHS among adolescents in rural Puducherry, South India.

METHODS

A community based cross-sectional study was conducted among adolescents during March and April 2018. Two out of four villages were selected randomly and all the adolescents were contacted through household visit and questionnaire was administered. Semi structured questionnaire contained three sections: sociodemographic details, environmental assessment and third section contained knowledge about SHS, COTPA and response towards being exposed to SHS, as well as exposure history. Continuous variables like age were summarized as mean (SD). Categorical variables such as awareness, attitude and practise towards SHS were summarized as proportions with 95% confidence interval.

RESULTS

Total number of adolescents interviewed was 789. The mean age of the study participants were 14.1 (2.4) years and majority, 440 (55.8%) were boys and 684 (86.7%) belonged to nuclear family. More than one fourth, 210 (26.6%) belonged to middle class of socio-economic status. Environmental assessment of household showed more than half, 456 (57.8%) were staying in pucca house and majority 642 (81.4%) had adequate cross ventilation. It was found that about 70.1% had adequate knowledge about SHS and its harmful effects. Prevalence of exposure to SHS was 49%. Majority (40.5%) told that they will scold or advice the family member to stop smoking if they are exposed to SHS in the living place. However, almost 80% of adolescents mentioned that they will no't react if they see someone smoking in a public place.

CONCLUSIONS

Current study found that almost half of the adolescents were exposed to SHS. Even though, almost three fourth had adequate knowledge, attitude towards preventing SHS in public place was found to be poor. Hence, adolescents need to be motivated enough to address the problem in the public place through motivational counselling in adolescent clinics by health care workers.

Exploring a broader context of the home environment and its relationship with asthma control in American Indian children

In this cross-sectional study of 60 American Indian mother-child dyads from Southeastern North Carolina, we examined whether childhood asthma control was related to household-level factors, such as environmental tobacco smoke and family management behaviors. We also examined the relationships among family management behaviors and maternal depressive symptoms. We used logistic regression to assess the relationships among childhood asthma control, the presence of environmental tobacco smoke, and family management behaviors, specifically condition management ability (CMA) and condition management effort (CME). We used linear regression to evaluate the relationships between both CMA and CME and maternal depressive symptoms. Better asthma control in children was associated with the absence of environmental tobacco smoke in the home and the maternal perception of asthma as a manageable condition. Mothers perceived an increase in effort to manage their child's asthma as their depressive symptoms increased. These findings emphasize the importance of environmental triggers, perceptions of condition management, and maternal mental health in controlling asthma in American Indian children. Interventions to reduce environmental triggers, treat maternal depressive symptoms, and support mothers in their ability to manage childhood asthma may yield better asthma control and help to reduce existing racial disparities in this population.

Glutathione S-Transferase Genotype Protects against In Utero Tobacco-linked Lung Function Deficits

Rationale: In utero tobacco exposure is associated with reduced lung function from infancy. Antioxidant enzymes from the glutathione S-transferase (GST) family may protect against these lung function deficits.Objectives: To assess the long-term effect of in utero smoke exposure on lung function into adulthood, and to assess whether GSTT1 and GSTM1 active genotypes have long-term protective effects on lung function.Methods: In this longitudinal study based on a general population (n = 253), lung function was measured during infancy and at 6, 11, 18, and 24 years. GSTM1 and GSTT1 genotype was analyzed in a subgroup (n = 179). Lung function was assessed longitudinally from 6 to 24 years (n = 199).Measurements and Main Results: Exposure to maternal in utero tobacco was associated with lower FEV₁ and FVC longitudinally from 6 to 24 years (mean difference, -3.87% predicted, P = 0.021; -3.35% predicted, P = 0.035, respectively). Among those homozygous for the GSTM1-null genotype, in utero tobacco exposure was associated with lower FEV₁ and FVC compared with those with no in utero tobacco exposure (mean difference, -6.2% predicted, P = 0.01; -4.7% predicted, P = 0.043, respectively). For those with GSTM1 active genotype, there was no difference in lung function whether exposed to maternal in utero tobacco or not. In utero tobacco exposure was associated with deficits in lung function among those with both GSTT1-null and GSTT1-active genotypes.Conclusions: Certain GST genotypes may have protective effects against the long-term deficits in lung function associated with in utero tobacco exposure. This offers potential preventative targets in antioxidant pathways for at-risk infants of smoking mothers.

2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation, the American Geriatrics Society, the American Society of Preventive Cardiology, and the Preventive Cardiovascular Nurses Association

2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

1. The most important way to prevent atherosclerotic vascular disease, heart failure, and atrial fibrillation is to promote a healthy lifestyle throughout life.

2. A team-based care approach is an effective strategy for the prevention of cardiovascular disease. Clinicians should evaluate the social determinants of health that affect individuals to inform treatment decisions.

3. Adults who are 40 to 75 years of age and are being evaluated for cardiovascular disease prevention should undergo 10-year atherosclerotic cardiovascular disease (ASCVD) risk estimation and have a clinician–patient risk discussion before starting on pharmacological therapy, such as antihypertensive therapy, a statin, or aspirin. The presence or absence of additional risk-enhancing factors can help guide decisions about preventive interventions in select individuals, as can coronary artery calcium scanning.

4. All adults should consume a healthy diet that emphasizes the intake of vegetables, fruits, nuts, whole grains, lean vegetable or animal protein, and fish and minimizes the intake of trans fats, processed meats, refined carbohydrates, and sweetened beverages. For adults with overweight and obesity, counseling and caloric restriction are recommended for achieving and maintaining weight loss.

5. Adults should engage in at least 150 minutes per week of accumulated moderate-intensity physical activity or 75 minutes per week of vigorous-intensity physical activity.

6. For adults with type 2 diabetes mellitus, lifestyle changes, such as improving dietary habits and achieving exercise recommendations are crucial. If medication is indicated, metformin is first-line therapy, followed by consideration of a sodium-glucose cotransporter 2 inhibitor or a glucagon-like peptide-1 receptor agonist.

7. All adults should be assessed at every healthcare visit for tobacco use, and those who use tobacco should be assisted and strongly advised to quit.

8. Aspirin should be used infrequently in the routine primary prevention of ASCVD because of lack of net benefit.

9. Statin therapy is first-line treatment for primary prevention of ASCVD in patients with elevated low-density lipoprotein cholesterol levels (≥190 mg/dL), those with diabetes mellitus, who are 40 to 75 years of age, and those determined to be at sufficient ASCVD risk after a clinician–patient risk discussion.

10. Nonpharmacological interventions are recommended for all adults with elevated blood pressure or hypertension. For those requiring pharmacological therapy, the target blood pressure should generally be <130/80 mm Hg.

Implementing smoke-free policies in low- and middle-income countries: A brief review and research agenda

INTRODUCTION

Some low- and middle-income countries (LMICs) struggle to implement smoke-free policies. We sought to review the academic and gray literature, and propose a research agenda to improve implementation of smoke-free policies and make them more effective in LMICs.

METHODS

We reviewed 10 databases for variations of (‘implementation’ /‘enforcement’ /‘compliance’) and (‘smoke-free’ /‘ban’ /‘restriction’) and (‘tobacco’ /‘smoking’). We also reviewed cited sources and the gray literature including non-governmental organization reports.

We included articles that described problems that arose, attempted solutions, lessons learned, and research questions posed regarding smoke-free policy implementation in LMICs. We excluded studies of high-income countries, institution-level implementation, voluntary smoke-free policies, smoke-free homes, and outdoor smoke-free policies.

RESULTS

The academic literature review led to 4931 unique articles, reduced to 1541 after title screening, 331 after abstract screening, and 101 after full-text review. The citation and gray literature review led to an additional 179 publications of which 67 met the inclusion criteria. In total we retained 168 sources. We conducted a narrative review and synthesis of the literature, extracting key themes and noting research gaps.

CONCLUSIONS

We find that progress is urgently needed in five categories: identifying the critical lessons learned for effective implementation, evaluating different enforcement approaches, learning how to rejuvenate stalled smoke-free policies, learning how to increase ground-level will to enforce policies, and developing a conceptual framework that explains implementation. Investigation into these topics can improve implementation of smoke-free policies in LMICs.

Factors Influencing Exposure to Secondhand Smoke: Passive Inhalation in Student Nurses

Objectives

To examine the factors affecting passive exposure to secondhand smoke (SHS) in non-smoking student nurses.

Methods

A cross-sectional study was performed in 196 college students who had not smoked cigarettes in the past 12 months. Urinary cotinine levels were examined to identify exposure to SHS, and social factors were identified that influenced exposure to SHS, including requests that smokers extinguish cigarettes. Logistic regression analysis was used to predict the factors influencing SHS.

Results

Urinary cotinine measurements showed that 32 students (16.3%) were exposed to SHS. Risk factors that increased exposure to SHS affected 80 students (40.8%) in the previous 7 days. Students who were exposed to SHS were 4.45-times more likely to have increased urinary cotinine levels than those who were not exposed. Students who asked others to extinguish their cigarettes were 0.34 times less likely to test positive than those who did not.

Conclusion

Urinary cotinine was a useful biomarker for identifying exposure to SHS, with respect to the influence of demographic, health-related, and smoking-related factors. In non-smoking nursing students, avoiding exposure to SHS was attributed to self-assertive behavior by requesting smokers to extinguish cigarettes.

Secondhand smoking, knowledge/attitudes and socioeconomic status among married Bangladeshi women: a cross-sectional study

BACKGROUND

There is a paucity of research on knowledge/attitudes regarding the dangers of exposure to secondhand smoking (SHS) among women. The relationship between exposure to SHS, socioeconomic status (SES) and knowledge/attitudes regarding the risks of SHS has often been ignored. We therefore aimed to examine (1) whether SES and exposure to SHS were independently associated with knowledge/attitudes regarding the risks of SHS; and (2) whether women with low SES and exposure to SHS were uniquely disadvantaged in terms of deficient knowledge and more dismissive attitudes towards the risks of SHS.

DESIGN AND SETTING

Cross-sectional study in the Rajshahi district, Bangladesh.

METHODS

A total of 541 women were interviewed. Knowledge of and attitudes towards the risks of SHS were the outcomes of interest.

RESULTS

A majority of the respondents were exposed to SHS at home (49.0%). Only 20.1% had higher levels of knowledge, and only 37.3% had non-dismissive attitudes towards the risks of SHS. Participants in the low SES group and those exposed to SHS had lower odds of higher knowledge and their attitudes towards the risks of SHS were more dismissive. Regarding deficient levels of knowledge and scores indicating more dismissive attitudes, women in the low SES group and who were exposed to SHS were not uniquely disadvantaged.

CONCLUSIONS

Exposure to SHS and low SES were independently associated with deficient knowledge and scores indicating more dismissive attitudes. Regarding knowledge/attitudes, the negative effect of exposure to SHS extended across all socioeconomic backgrounds and was not limited to women in either the low or the high SES group.

Disparities in Rural Tobacco Use, Smoke-Free Policies, and Tobacco Taxes

Tobacco use and exposure to secondhand smoke (SHS) remain leading causes of preventable disease, disability, and mortality in the United States. Rural populations are among those being left behind in the recent declining smoking rates and have become a focus of discussions on tobacco-related disparities. This article describes tobacco-related disparities in rural populations including tobacco use, exposure to SHS, smoke-free policies, and tobacco taxes. Nurses, as social justice and tobacco control policy advocates, are needed especially at the local level, where much of the policy work occurs and where nursing's voice is respected and can be powerful.

Comparison Between Pediatricians and Physicians in Other Medical Specialties in Promoting Smoking Cessation in the Clinic

Background

Louisiana has one of the highest rates of smoking in the country, putting its children at high risk of secondhand and third-hand smoke exposure and subsequent morbidity. Pediatricians have an important role to play by including smoking cessation promotion (SCP) in their discussions with patient caregivers. The purpose of this study was to examine SCP trends at Ochsner Health System and to determine if pediatricians are less likely to express confidence in and performance of SCP activities than physicians in other specialties.

Methods

We distributed a survey to pediatricians and to physicians in the departments of obstetrics and gynecology, internal medicine, and psychiatry in the Ochsner Health System. The survey assessed physician confidence in and performance of several SCP behaviors. We analyzed pediatrician confidence in and performance of 3 behaviors (screening, counseling, and referring) and compared pediatrician responses to the responses of the physicians in the other specialties.

Results

Twenty-eight pediatrician and 33 other physician responses were included in the analysis. No significant correlation (P = 0.2785) was found between pediatrician confidence and performance in screening for smoking behavior. A significant correlation was found in counseling (P = 0.0159) and referring (P = 0.0214). In the comparison of pediatrician responses to other physician responses, the physicians in the other specialties had higher medians and/or quartiles for both confidence and performance of all 3 behaviors, and the differences were significant.

Conclusion

The physicians in other specialties showed consistently higher rates of confidence and performance of SCP behaviors than the pediatricians. Intervention is necessary to encourage pediatricians at Ochsner Health System to promote smoking cessation in their practices.

The toxicology of air pollution predicts its epidemiology

The epidemiologic investigation has successively delineated associations of air pollution exposure with non-malignant and malignant lung disease, cardiovascular disease, cerebrovascular disease, pregnancy outcomes, perinatal effects and other extra-pulmonary disease including diabetes. Defining these relationships between air pollution exposure and human health closely parallels results of an earlier epidemiologic investigation into cigarette smoking and environmental tobacco smoke (ETS), two other particle-related exposures. Humic-like substances (HULIS) have been identified as a chemical component common to cigarette smoke and air pollution particles. Toxicology studies provide evidence that a disruption of iron homeostasis with sequestration of host metal by HULIS is a fundamental mechanistic pathway through which biological effects are initiated by cigarette smoke and air pollution particles. As a result of a common chemical component and a shared mechanistic pathway, it should be possible to extrapolate from the epidemiology of cigarette smoking and ETS to predict associations of air pollution exposure with human disease, which are currently unrecognized. Accordingly, it is anticipated that the forthcoming epidemiologic investigation will demonstrate relationships of air pollution with COPD causation, peripheral vascular disease, hypertension, renal disease, digestive disease, loss of bone mass/risk of fractures, dental disease, eye disease, fertility problems, and extrapulmonary malignancies.

Childhood and adult exposure to secondhand tobacco smoke and cardiac structure and function: results from Echo-SOL

Objective

To describe the relationship of household secondhand smoke (SHS) exposure and cardiac structure and function.

Methods

Participants (n=1069; 68 % female; age 45–74 years) without history of tobacco use, coronary artery disease or severe valvular disease were included. Past childhood (starting at age <13 years), adolescent/adult and current exposure to household SHS was assessed. Survey linear regression analyses were used to model the relationship of SHS exposure and echocardiographic measures of cardiac structure and function, adjusting for covariates (age, sex, study site, alcohol use, physical activity and education).

Results

SHS exposure in childhood only was associated with reduced E/A velocity ratio (β=−0.06 (SE 0.02), p=0.008). SHS exposure in adolescence/adult only was associated with increased left ventricular ejection fraction (LVEF) (1.2 (0.6), p=0.04), left atrial volume index (1.7 (0.8), p=0.04) and decreased isovolumic relaxation time (−0.003 (0.002), p=0.03). SHS exposure in childhood and adolescence/adult was associated with worse left ventricular global longitudinal strain (LVGLS) (two-chamber) (0.8 (0.4), p= 0.049). Compared with individuals who do not live with a tobacco smoker, individuals who currently live with at least one tobacco smoker had reduced LVEF (−1.4 (0.6), p=0.02), LVGLS (average) (0.9 (0.40), p=0.03), medial E′ velocity (−0.5 (0.2), p=0.01), E/A ratio (−0.09 (0.03), p=0.003) and right ventricular fractional area change (−0.02 (0.01), p=0.01) with increased isovolumic relaxation time (0.006 (0.003), p=0.04).

Conclusions

Past and current household exposure to SHS was associated with abnormalities in cardiac systolic and diastolic function. Reducing household SHS exposure may be an opportunity for cardiac dysfunction prevention to reduce the risk of future clinical heart failure.

Exposure to Secondhand Smoke and Risk of Cancer in Never Smokers: A Meta-Analysis of Epidemiologic Studies

This is first meta-analysis to evaluate cancer risk associated with secondhand smoking across all cancers. A literature search was conducted for articles published before June 2014 on Pubmed, SCOPUS, Cochrane library, and CINAHL, and 40 articles on secondhand smoke and the prevalence of cancer among never smokers were selected for final analysis as per the inclusion criteria. Of the 40 articles, 27 were case-control studies and 13 were prospective cohort studies. With respect to overall cancer risk, odds ratio (OR) involving never smokers with significant exposure to secondhand smoke compared to never smokers without such exposure was 1.163 (95%CI 1.058–1.279). Subgroup meta-analyses by study design showed significant positive associations for both case-control studies and prospective cohort studies (OR 1.165, 95%CI 1.029–1.320; and OR 1.160, 95%CI 1.002–1.343, respectively). The association was stronger in the case of females (OR 1.253, 95%CI 1.142–1.374), lung cancer (OR 1.245, 95%CI 1.026–1.511), and breast cancer (OR 1.235, 95%CI 1.102–1.385). Secondhand smoking may increase the overall risk of cancer for never smokers, particularly lung and breast cancer, and especially in women. Strict implementation of smoking cessation programs should be encouraged, not only to reduce active smoking but also to limit exposure to secondhand smoke.

Predicting students' noncompliance with a smoke-free university campus policy

The adoption of university campus smoke-free and tobacco-free policies has risen dramatically, but research on effective implementation is scant. Significant challenges exist regarding policy implementation, particularly enforcement. This study examined college students' noncompliance with a recently implemented smoke-free campus policy at a public university. The sample included students who reported past-month smoking of tobacco or e-cigarettes in a 2013 web-based survey, 9 months after a smoke-free campus policy took effect. Ordinal logistic regression was used to examine predictors of students' having smoked on campus since the policy began (n = 1055). Predictor variables included past-month use of cigarettes, e-cigarettes, smokeless tobacco, and non-cigarette tobacco products, secondhand smoke (SHS) exposure, support for a smoke-free campus, tobacco-related social norms, use of strategies to deal with smoking urges, and other variables. In multivariate analysis, policy violation was positively associated with past-month use of cigarettes and non-cigarette combustible tobacco, SHS exposure on campus, living on campus, and use of nicotine gum/patches to handle urges. Violation was negatively associated with smoke-free campus support, age, estimates of student policy support and cigarette smoking, and self-reported absence of smoking urges. Results suggest that nicotine dependence may be an underlying influence on policy violation. Several recommendations are offered. First, upon policy adoption, campuses should ensure student smokers' access to cessation support and assistance with dealing with nicotine cravings. Second, campus information campaigns should focus particularly on younger students and those living on campus. Third, campuses should establish strong anti-tobacco norms, monitor SHS exposure, and communicate levels of students' policy support.

Measures stated by parents and caregivers of infants, toddlers, and preschoolers to prevent environmental tobacco smoke exposure

INTRODUCTION

The exposure to environmental tobacco smoke is a public health problem because of its potential risks for children. Objective. To determine the preventive actions taken by parents and/or caregivers of infants, toddlers, and preschoolers regarding environmental tobacco smoke exposure. Methods. Cross-sectional, analytical study in parents and caregivers of infants, toddlers, and preschoolers from Valdivia, Chile. A questionnaire on preventive measures regarding environmental tobacco smoke was administered. The questionnaire was analyzed with descriptive and association statistics using Fisher's exact test and logistic regression to calculate the odds ratios (ORs) and their corresponding 95% confidence intervals (95% CIs) as an estimation of the risk for not taking preventive measures at home.

RESULTS

A total of 469 parents and caregivers participated. The prevalence of households with one member who smoked was 51.8%. Most of them smoked outside the house (92.2%). The most common measure taken outside the household was to avoid places where people smoked. In this setting, a significant difference was observed between men and women in relation to avoiding exposure (7.6% versus 2.2%; p= 0.040). A higher risk for not avoiding tobacco use inside or outside the housewas confirmed when a household member smoked (OR: 3.55; 95% CI: 2.05-6.14). Also, a lower risk was observed when there were two or more children in the household (OR: 0.46; 95% CI: 0.26-0.83).

CONCLUSIONS

Most parents and caregivers ask others to smoke outside and avoid places where people smoke; however, the level of prevention is lower among households with smokers.

A framework for measurement and harmonization of pediatric multiple sclerosis etiologic research studies: The Pediatric MS Tool-Kit

Background:

While studying the etiology of multiple sclerosis (MS) in children has several methodological advantages over studying etiology in adults, studies are limited by small sample sizes.

Objective:

Using a rigorous methodological process, we developed the Pediatric MS Tool-Kit, a measurement framework that includes a minimal set of core variables to assess etiological risk factors.

Methods:

We solicited input from the International Pediatric MS Study Group to select three risk factors: environmental tobacco smoke (ETS) exposure, sun exposure, and vitamin D intake. To develop the Tool-Kit, we used a Delphi study involving a working group of epidemiologists, neurologists, and content experts from North America and Europe.

Results:

The Tool-Kit includes six core variables to measure ETS, six to measure sun exposure, and six to measure vitamin D intake. The Tool-Kit can be accessed online (www.maelstrom-research.org/mica/network/tool-kit).

Conclusion:

The goals of the Tool-Kit are to enhance exposure measurement in newly designed pediatric MS studies and comparability of results across studies, and in the longer term to facilitate harmonization of studies, a methodological approach that can be used to circumvent issues of small sample sizes. We believe the Tool-Kit will prove to be a valuable resource to guide pediatric MS researchers in developing study-specific questionnaire

Social inequalities in secondhand smoke exposure in children in Spain

INTRODUCTION

Children are particularly vulnerable to the health effects of secondhand smoke (SHS). The objectives of this study are to describe SHS exposure of children younger than 12 years in Spain and to identify potential social inequalities associated with SHS exposure.

METHODS

A cross-sectional study was conducted in a representative sample of the population younger than 12 years in Spain. A computer-assisted telephone interview was conducted with parents or legal guardians in 2016, to assess the children’s SHS exposure at home, in the car, at school and at the nursery gates, in public transport, and during leisure time. The socio-demographic variables included were the child’s age and sex, the highest educational attainment at home, and occupational social class. Prevalence and 95% confidence intervals were calculated for SHS exposure in each setting and for overall exposure.

RESULTS

In all, 71.8% of the children were exposed to SHS: 25.8% were exposed at home, 4.6% in the car, 8.2% in public transport, 31.9% at outdoor nursery or school gates, and 48% during leisure time. The higher the educational attainment at home, the lower the exposure (38.8% for primary school or lower, 28.7% for secondary school and 20.8% university level). The more deprived the social class, the higher the exposure (21.7% class I-II, 23.4% class III-IV and 31.1% class V-VII). SHS exposure in cars and overall exposure also decreased with higher educational achievement.

CONCLUSIONS

In Spain, a large proportion of children are still exposed to SHS. Furthermore, there are clear social inequalities. To reduce SHS exposure, there is an urgent need for evidence-based interventions with an equity perspective.

Effect of Secondhand Smoking, Determined by Urinary Cotinine Level on Bone Health

Background:

We evaluated the relationship between secondhand smoke (SHS) inhalation, as verified by urinary cotinine levels, and bone health.

Methods:

We analyzed the nationwide, population-based, cross-sectional health survey. We included 1936 men aged 50 years or older who checked bone mineral density (BMD) from the Korean National Health and Nutrition Examination Survey (2008–2010). Current smokers assessed by urinary cotinine levels higher than 500 ng/mL were excluded (n = 616). Exposure to SHS was determined using a 50 ng/mL urinary cotinine threshold.

Results:

The estimated prevalence of SHS exposure in our cohort was 13.9%. After adjusting for age and body mass index (BMI), T-scores at total femur (P < 0.001), femoral neck (P < 0.001), and lumbar spine (P = 0.004) were lower in SHS exposure versus nonexposure groups. Impaired bone health (osteopenia or osteoporosis) at femoral neck or lumbar spine was evident in 61.7% and 48.6% of SHS exposure and nonexposure cases, respectively (P = 0.004). Moreover, after adjusting for age, BMI, and health habits, the odds ratio for impaired bone health in the SHS exposure group was 1.89 (95% confidence interval: 1.31–2.74).

Conclusions:

Our findings suggest that SHS exposure, determined by urinary cotinine levels, is negatively associated with BMD and is a leading cause of impaired bone health in Korean men.

Second-hand smoke prevalence in 252 regions of South Korea in three exposure locations

PURPOSE

The association between regional contextual factors and second-hand smoke (SHS) prevalence is important, but is unclear. This study investigated the changes of SHS prevalence from 2011 to 2013 and explored the correlations of SHS prevalence and regional contextual factors by exposure location.

METHODS

The data were obtained from the 2011 and 2013 Korean Community Health Survey and the Development of Health Indicators for Community Health Ranking report. A t-test was used to examine and compare the SHS prevalence in 2011 and 2013 by exposure location (home, workplace, and public places). A correlation analysis and linear regression were used to investigate the impacts of the regional variables on SHS prevalence by location.

RESULTS

The prevalence of SHS in all three locations had a decreased trend overall, but remained high in public locales. There were clear differences in the prevalence of SHS and its change by region between 2011 and 2013. The SHS prevalence in the workplace and public places had increased in the high social and economic characteristic regions, compared to the other regions in 2 years. The SHS had an increased trend in regions featuring a high level of socioeconomic development. It was observed that regional factors affecting SHS prevalence differed in the three locations.

CONCLUSION

The differences and changes of regional SHS prevalence by location were influenced by specific social contextual factors of the particular region. Local government initiatives regarding special SHS protective measures or tailored regulations, according to specific regional status and location, are recommended, with attention to high socioeconomic regions in particular.

Association of Smoking in the Home With Lung Cancer Worry, Perceived Risk, and Synergistic Risk

PURPOSE/OBJECTIVES

To examine the association of smoking in the home with lung cancer worry, perceived risk, and synergistic risk, controlling for sociodemographics, family history of lung cancer, and health-related self-concept. The hypothesis is that participants with smoking in the home would have higher scores for lung cancer worry, perceived risk, and synergistic risk.
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DESIGN

Cross-sectional baseline survey. 
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SETTING

Participants recruited from an outpatient clinic and pharmacy at University of Kentucky HealthCare, an academic medical center.
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SAMPLE

515 homeowners from a larger randomized, controlled trial aimed at reducing exposure to radon and secondhand smoke (SHS).
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METHODS

Homeowners were selected via quota sampling so that about half would have a smoker or smokers in the home.
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MAIN RESEARCH VARIABLES

Lung cancer worry and perceived risk; perception of synergistic risk of radon and SHS exposure; demographics.
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FINDINGS

Participants with smoking in the home had higher rates of lung cancer worry and perceived risk. In addition, those with less education and a family history of lung cancer and who were current smokers had higher lung cancer worry and perceived lung cancer risk scores. Predictors of perception of synergistic risk were marital status and health-related self-concept.
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CONCLUSIONS

Homeowners with smoking in the home, less education, and a family history of lung cancer had greater lung cancer worry and perceived lung cancer risk. Lung cancer risk reduction interventions with vulnerable populations are needed. 
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IMPLICATIONS FOR NURSING

Nurses are in a unique position to target high-risk populations and identify opportunities to create teachable moments to reduce environmental risks of radon and tobacco smoke exposure.

Impact of Presence of Children on Indoor Tobacco Restrictions in Households of Urban and Rural Adult Tobacco Users

OBJECTIVES

Secondhand smoke exposure in children is changing as a result of new public policy and electronic nicotine products (e-cigarettes). We examined factors related to self-imposed indoor household tobacco restrictions, with emphasis on children in the household and associations with combustible and noncombustible product use.

METHODS

A cross-sectional survey of urban and rural Ohio adult tobacco users classified participants as exclusive combustible users, smokeless tobacco (SLT) users, e-cigarette users, or dual users. They were further stratified according to combustible or noncombustible product use and the presence of indoor tobacco use restrictions. Multiple logistic regression determined factors associated with indoor tobacco restrictions.

RESULTS

A total of 1210 tobacco users participated, including 25.7% with children living in the home. Half allowed combustible and two thirds allowed noncombustible tobacco use indoors. Urban location (odds ratio [OR] = 1.58), younger age (OR = 0.88 per 5 year), male sex (OR = 1.40), college education (OR = 1.40), household income of more than $15,000 (OR = 1.78), and being married (OR = 2.43) were associated with a higher likelihood of banning combustible products indoors. SLT (OR = 8.12) and e-cigarette (OR = 5.85) users were more likely to have indoor bans compared to combustible users. Children in the household (OR = 1.89), older age (OR = 1.12 per 5 years), and nonwhite race (OR = 1.68) were associated with a higher likelihood of banning noncombustible products indoors. Combustible (OR = 4.54) and e-cigarette (OR = 3.04) users were more likely than SLT users to have indoor bans.

CONCLUSIONS

Indoor restrictions on tobacco use remain infrequent in homes with children and are associated with user type and socioeconomic factors. Public policy should target modifiable risk factors for in-home secondhand smoke exposure.