Secondhand tobacco smoke exposure and severity of influenza in hospitalized children

Effectiveness of cocoon strategy vaccination on prevention of influenza-like illness in young infants

During the initial half-year of their existence, infants cannot receive the influenza vaccine, yet they face the greatest susceptibility to severe influenza complications. In this study, we seek to determine whether influenza vaccination of maternal and household contacts is associated with a reduced risk of influenza-like illness (ILI) and severe acute respiratory infection (SARI) in infants. This work was prospectively conducted during the influenza season. A total of 206 infants were included in this study. The percentage of infants with only the mother vaccinated is 12.6% (n:26), and the percent of infants with all household contacts vaccinated is 16% (n:33). Among the infants with only the mother vaccinated, the effectiveness of influenza vaccine is estimated as 35.3% for ILI and 41.3% for SARI. Among infants with all household contacts vaccinated, the effectiveness is estimated as 48.9% for ILI and 76.9% for SARI. Based on the results of multivariate logistic regression analysis, all-household vaccination is a protective factor against SARI (OR: 0.07 95% CI [0.01-0.56]), household size (OR: 1.75, 95% CI [1.24-2.48]) and presence of secondhand smoke (OR: 2.2, 95% CI [1.12-4.45]) significant risk factors for SARI in infants. The mother alone being vaccinated is not a statistically significant protective factor against ILI (OR: 0.46, 95% CI [0.19-1.18]) or SARI (OR: 0.3, 95% CI [0.11-1.21]). Along with the obtained results and analysis, this study provides clear evidence that influenza vaccination of all household contacts of infants aged 0-6 months is significantly associated with protecting infants from both ILI and SARI.

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

IMPACT

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

Intervening With Smoking Parents of Inpatients to Reduce Exposure: The INSPIRE Randomized Controlled Trial

BACKGROUND

Hospitalized children have high rates of tobacco smoke exposure; parents who smoke may be receptive to interventions during their child's hospitalization.

OBJECTIVE

We tested the efficacy of a smoking cessation intervention for parents of hospitalized children.

METHODS

We conducted a randomized, single-blind clinical trial from 12/14-5/18 at the Children's Hospital Colorado. Hospitalized children who had a parent who smoked tobacco were eligible.

INTERVENTION

Intervention participants received motivational interviewing sessions, 2 weeks of nicotine replacement therapy; both groups received referral to the Quitline Consenting parents completed a questionnaire; urine was collected from the child for measurement of cotinine. Our primary outcome was: 1) increase in reporting "no one is allowed to smoke anywhere" in the home (smoke-free home rule). Additional outcomes included: 2) change in child's cotinine from baseline to 1 year, and 3) parental quitting at 1 year. Data were analyzed using Chi-square and t tests for bivariable data, and multivariable logistic and linear regression.

RESULTS

Of 1641 eligible families approached, 252 were randomized (15%); 149 families had follow-up data at 12 months (59%). In the adjusted analysis, there was no difference between the groups in smoke free home rules, or child cotinine level; in an intention-to-treat analysis, 15% in the intervention group versus 8% of controls reported quit (p=0.07).

CONCLUSIONS

A smoking cessation intervention can be delivered to parents of hospitalized children. While hospitalization provides an opportunity to help parents quit smoking, more efficient and effective engagement strategies are needed to optimize tobacco control success.

Barriers and Motivators for Smoking Cessation Among Caregivers of Inpatient Pediatric Patients

OBJECTIVE

To examine perceived barriers and motivators for smoking cessation among caregivers of inpatient pediatric patients.

METHODS

From December 2014 to June 2018, trained tobacco counselors conducted motivational interviews (MI) with caregivers of inpatient pediatric patients ages 0 to 17, who participated in the intervention arm of a smoking cessation randomized controlled trial. By using NVivo 12 software, the first MI session with each caregiver was evaluated by 3 individuals to identify and categorize motivators and barriers; agreement among reviewers was reached. Barriers and motivators were examined in bivariable analysis with χ2 or Fisher's exact tests for categorical factors and with t-tests for continuous factors by using SAS 9.4 software.

RESULTS

Of the 124 caregivers randomized to intervention, 99 subjects (80%) completed ≥1 MI sessions. The most prevalent barriers to cessation were stress (57%) and social influence (37%).The most prevalent motivators were desire to lead a healthy life (54%) and desire to improve the child and family's well-being (47%). Older parent age was associated with wanting to lead a healthy life, and younger child age was associated with wanting to improve the child and family's well-being.

CONCLUSIONS

Understanding barriers and motivators to cessation among caregivers is crucial in reducing pediatric secondhand smoke (SHS). When developing caregiver cessation programs in an inpatient clinic encounter, caregiver barriers and motivators may help in targeting education and strategies to help counselors and clinicians better identify and support caregivers who wish to quit smoking.

Monthly Motivational Interview Counseling and Nicotine Replacement Therapy for Smoking Parents of Pediatric Patients: A Randomized Controlled Trial

BACKGROUND

Parental smoking is the dominant source of passive smoke exposure in the pediatric population. The current randomized controlled trial (RCT) study aimed to evaluate the effectiveness of a multi-component smoking reduction intervention in parental smoking reduction and children's environmental tobacco smoke exposure reduction in clinical settings.

METHODS

A single-blinded, 6-month randomized controlled trial recruited smoking parents (N = 210) of children who attended the pediatric wards or clinics at the Prince of Wales Hospital. Participants allocated to the intervention group (n = 105) received monthly motivational interviews on smoking reduction with emphasis on health hazards related to children's passive smoke exposure, 8-week nicotine replacement therapy, and referral to smoking cessation service if the parents preferred. The control group (n = 105) received simple verbal advice on smoking cessation. Primary outcomes were parental urine cotinine validated and self-reported ≥50% smoking reduction rates at 6 months.

RESULTS

Smoking parents in the intervention group had significantly more biochemically validated ≥50% smoking reduction than the control: 27.1 vs. 10.0% (OR = 3.34, 95% CI: 1.16-9.62, P = 0.02). The rate of self-reported ≥50% smoking reduction was also significantly higher in the intervention group than the control: 51.9 vs. 20.2% (OR = 4.40, 95% CI: 2.38-8.12, P < 0.001). For secondary outcomes, the rate of parental self-reported smoking cessation was higher in the intervention arm: 10.5 vs. 1.0% (OR = 12.17, 95% CI: 1.54-96.07, P < 0.001), however, no differences were detected in biochemically validated cessation and changes in children's passive smoke exposure between the groups.

CONCLUSION

Monthly smoking reduction counseling together with nicotine replacement therapy is more effective than simple verbal cessation advice in the smoking reduction for parents of pediatric patients. However, this study did not demonstrate differences in smoking cessation or reduction in children's passive smoke exposure with a 6-month follow-up. Achievement of a smoke-free environment remains challenging.

TRIAL REGISTRATION

Clinicaltrials.gov, identifier: NCT03879889.

Smoke Exposure Disclosure: Parental Perspectives of Screening in the Inpatient Setting

OBJECTIVES

Current screening questions for pediatric tobacco smoke exposure are suboptimal. Factors influencing screening accuracy, particularly in the pediatric inpatient setting, are unknown. Our objective was to identify facilitators of and barriers to parental disclosure of smoke exposure when screened during their child's hospitalization and strategies to promote accurate disclosure.

METHODS

This qualitative study was conducted with a convenience sample of parents of children admitted to the medical and surgical unit of a Midwest tertiary care children's hospital. Eligible parents included those with documented disclosure of smoke exposure in the child's electronic health record. A researcher trained in qualitative methods conducted semistructured, in-depth interviews with parents regarding their experiences with smoke exposure screening in the inpatient pediatric setting. Two researchers independently identified concepts directed at barriers, facilitators, and strategies for effective screening, which were compared and reconciled by a third researcher.

RESULTS

Facilitators of disclosing their child's smoke exposure included the following: (1) the caregiver's internal characteristic(s) promoting disclosure, (2) perceived relevance of the screening question to the child's health, and (3) the questioner being viewed positively. Barriers included the following: (1) fear of negative consequences, (2) a vague question, (3) lack of knowledge, (4) guilt, and (5) unconducive environment and timing. The strategies parents suggested to improve screening for smoke exposure included the following: (1) communicate preemptively, (2) provide specific exposure examples, (3) improve questioner-caregiver rapport, and (4) improve screening environment and timing.

CONCLUSIONS

Parents identified various mechanisms to improve tobacco smoke exposure screening. The facilitators, barriers, and strategies provide opportunities to improve the inpatient pediatric screening process.

Smoking Behaviors Among Tobacco-Using Parents of Hospitalized Children and Association With Child Cotinine Level

OBJECTIVES

Understanding patterns of parental tobacco use and their association with child exposure can help us target interventions more appropriately. We aimed to examine the association between parental smoking practices and cotinine levels of hospitalized children.

METHODS

This is a secondary analysis of data collected from parents of hospitalized children, recruited for a cessation intervention randomized controlled trial. Smoking parents were identified by using a medical record screening question. Parent-reported demographics and smoking habits were compared to child urine cotinine by using geometric means and log-transformed cotinine levels in multivariable linear regression analyses.

RESULTS

A total of 213 patients had complete baseline parent-interview and urine cotinine data. The median age was 4 (interquartile range: 1-9); 57% were boys; 56% were white, 12% were Black, and 23% were multiracial; 36% identified as Hispanic. Most families (54%) had 1 smoker in the home; 36% had 2, and 9% had ≥3. Many (77%) reported having a ban on smoking in the home, and 86% reported smoking only outside. The geometric mean cotinine level of the cohort was 0.98 ng/mL. Higher cotinine levels were associated with more smokers in the home (ratio of 2.99) and smoking inside the house (ratio of 4.11).

CONCLUSIONS

Having more smokers in the home and parents who smoke inside are associated with increased smoke exposure; however, even children whose families who smoke only outside the home have significant levels of cotinine, a marker for toxin exposure.

Maternal Smoking in Pregnancy and Child's Hospital Use up to 5 Years of Age in a Data Linkage Birth Cohort

OBJECTIVES

To examine if exposure to maternal smoking during pregnancy is associated with emergency department (ED) presentation and admission through the ED in children up to 5 years after birth.

METHODS

Antenatal records of all children up to 5 years of age who were born in Tasmania, Australia, between July 2008 and June 2014 were linked to health service use (ED presentations and hospital admissions). Negative binomial regression was used to estimate the incidence rate ratio (IRR) and 95% confidence intervals (CIs) at ≤1 year and ≤5 years for ED presentations and admissions to the hospital through the ED for any reason and by 9 major disease categories for children exposed versus children not exposed to maternal smoking during pregnancy. Models were adjusted for sex, socioeconomic position, maternal age at birth, and region of residence. Presentations and admissions for poisoning and injuries were used as a negative control.

RESULTS

Among 36 630 infants, 21% were exposed to maternal smoking during pregnancy. Exposed children had a 26% higher rate of presentation to the ED (IRR_adjusted 1.26; 95% CI 1.23-1.29) and a 45% higher rate of admission (IRR_adjusted 1.45; 95% CI 1.39-1.51) at up to 5 years of age. Compared with the negative control, higher presentation and admission rates were evident in respiratory; eyes, ears, nose, and throat; psychosocial; and infectious disease categories.

CONCLUSIONS

Higher health care service use was observed in children exposed to maternal smoking during pregnancy for a range of conditions associated with exposure to smoking. The findings reinforce the need to reduce smoking among people in their childbearing years.

Child tobacco smoke exposure and healthcare resource utilization patterns

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

IMPACT

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

Passive Smoking and Disease Severity in Childhood Pneumonia Under 5 Years of Age

OBJECTIVE

To objectively investigate the effect of passive smoking on pneumonia and disease severity in children aged less than 5 years by using cotinine as an indicator of passive smoking.

METHODS

Between December 2015 and April 2016, children aged less than 5 years with pneumonia and age-matched healthy controls were included in this study, which was conducted at three tertiary pediatric pulmonology centers. A questionnaire was given to the parents regarding demographic data and smoking status at home. Urinary cotinine/creatinine ratio (CCR) was measured. The data from the pneumonia and control groups, as well as children with mild and severe pneumonia within the pneumonia group, were compared.

RESULTS

A total of 227 subjects were included in the study; there were 74 children in the pneumonia group and 153 in the control group. The mean age of all the children was 33.4 ± 1.28 months. Of all subjects, 140 were male and 102 were exposed to passive smoking by their parents at home. There were statistically significant differences in age, number of people in the home, and mother's and father's age between the control and pneumonia groups (p < 0.05). No difference was found in the CCR in the control and pneumonia group (p > 0.05). Age and urinary CCR were significantly different between children with mild and severe pneumonia (p < 0.05).

CONCLUSION

We showed that passive smoking exposure was associated with the development of severe pneumonia in children. Further studies are needed to examine the underlying cause in detail.

Prevalence of urinary cotinine levels in children under 5 years of age during consultations for acute respiratory disease at the emergency department of the Universidad de La Sabana clinic

BACKGROUND

Several environmental factors favour the occurrence of acute respiratory disease, which is the main reason for paediatric consultations in our country (Colombia). Tobacco smoke is considered a significant environmental pollutant with a great impact on health. The objective of this study is to estimate the prevalence of cotinine levels measured in urine, in children between 1 to 60 months of age who attended an emergency department with acute respiratory disease.

METHODS

A cross-sectional study was conducted that included children between 1 and 60 months of age with acute respiratory disease who were admitted to the emergency department of the Universidad de La Sabana Clinic between April and July 2016.

RESULTS

We included 268 patients and 36% were female. Of the total population examined, 33.96% showed positive results for urinary cotinine, of whom 97.8% had values between 10 and 100 ng/ml, which is considered positive for exposure to second-hand smoke. The principal pathology was recurrent wheezing in 43.96% of these cases. Regarding the presence of smokers at home, it is important to mention that in 54.95% of the children with positive urinary cotinine test was no related with smokers at home. And in 45.05% of positive urinary cotinine was evidence of smokers at home, being associated with the positive result P <  0.001 and smoking within the house P = 0.018; smoking when children were present did not have significant P = 0.105. The activities performed after smoking such as hand washing, change of clothes, eating, brushing teeth, did not influence the test result P = 0.627.

CONCLUSIONS

A high prevalence of urinary cotinine was observed, which is associated with the presence of a smoker at home, and this relationship was independent of the activities performed by the smoker after smoking. In addition, a positive test for urinary cotinine was presented in some children without documented exposure to cigarette smoke inside the home, which may be explained by the presence of environmental cotinine. Therefore, it is necessary to perform educational interventions aimed at parents and caregivers who smoke.

Passive Smoking Exposure and Perceived Health Status in Children Seeking Pediatric Care Services at a Vietnamese Tertiary Hospital

Understanding the predictors of health conditions and exposure to secondhand smoke among children is necessary to determine the severity of the issues and identify effective solutions. Despite the significant prevalence in smoking and child exposure to secondhand smoke, there have been only a few studies focusing on this area in Vietnam, and thus the current study aims to fill in this gap. The questionnaires of 435 children aged between 0 and 6 and their caregivers, who agreed to participate in the research, were collected at the Pediatric Department of Bach Mai hospital, Hanoi, in 2016. Multivariable logistic regression was employed to identify factors associated with perceived health status and exposure to secondhand smoke among children in the last 24 h and the last 7 days from the date of the survey. Our study found that 43% of the respondents had smokers in the family, and 46.4% of children were exposed to passive smoking in the last 7 days. Urban children were most frequently exposed to passive smoking at home and in public, whereas in the rural area, the home and relatives’ houses were the most common places for exposure. Compared to children whose caregivers were farmers, children of non-government workers were more likely to be exposed to passive smoking in the last 7 days. Moreover, children in a family having smoking rules and no smokers were less likely to be exposed to passive smoking in the last 24 h and 7 days than those living in a family allowing smoking and having smokers. In conclusion, our study shows that the government needs to implement better public smoking monitoring and encourage caregivers to implement smoke-free households or smoking rules in their houses.

Hydroquinone exposure alters the morphology of lymphoid organs in vaccinated C57Bl/6 mice

The influenza is a common viral infection that can be fatal, especially in high-risk groups such as children, pregnant women, elderly, and immune-deficient individuals. Vaccination is the most efficient approach to prevent the spreading of viral infection and promote individual and public health. In contrast, exposure to environmental pollutants such as cigarette smoke reduces the efficacy of vaccination. We investigated whether chronic exposure to hydroquinone (HQ), the most abundant compound of the tobacco particulate phase, could impair the adaptive immune responses elicited by influenza vaccination. For this, adult male C57BL/6 mice were daily exposed to either nebulized HQ or PBS for 1 h for a total of eight weeks. At weeks 6 and 8, the mice were primed and boosted with the trivalent influenza vaccine via IM respectively. Although the HQ exposure did not alter the body weight of the mice and the biochemical and hematological parameters, the pollutant increased the oxidative stress in splenocytes of immunized animals, modified the morphology of spleen follicles, and augmented the size of their lymph nodes. The lymphoid organs of HQ-exposed mice presented a similar number of vaccine-specific IgG-secreting cells, titers of vaccine-specific total IgG, and respective subclasses. Transcriptome studies with HQ, benzene, or cigarette smoke exposure were also analyzed. The genes up-regulated upon pollutant exposure were associated with neutrophil migration and were shown to be co-expressed with antibody-secreting cell genes. Therefore, these findings suggest that HQ exposure may trigger an immune-compensatory mechanism that enhances the humoral responses induced by influenza vaccination.

Viruses and non-allergen environmental triggers in asthma

Asthma is a complex inflammatory disease with many triggers. The best understood asthma inflammatory pathways involve signals characterized by peripheral eosinophilia and elevated immunoglobulin E levels (called T2-high or allergic asthma), though other asthma phenotypes exist (eg, T2-low or non-allergic asthma, eosinophilic or neutrophilic-predominant). Common triggers that lead to poor asthma control and exacerbations include respiratory viruses, aeroallergens, house dust, molds, and other organic and inorganic substances. Increasingly recognized non-allergen triggers include tobacco smoke, small particulate matter (eg, PM2.5), and volatile organic compounds. The interaction between respiratory viruses and non-allergen asthma triggers is not well understood, though it is likely a connection exists which may lead to asthma development and/or exacerbations. In this paper we describe common respiratory viruses and non-allergen triggers associated with asthma. In addition, we aim to show the possible interactions, and potential synergy, between viruses and non-allergen triggers. Finally, we introduce a new clinical approach that collects exhaled breath condensates to identify metabolomics associated with viruses and non-allergen triggers that may promote the early management of asthma symptoms.

Home Smoke Exposure and Health-Related Quality of Life in Children with Acute Respiratory Illness

OBJECTIVE

This study aims to assess whether secondhand smoke (SHS) exposure has an impact on health-related quality of life (HRQOL) in children with acute respiratory illness (ARI).

METHODS

This study was nested within a multicenter, prospective cohort study of children (two weeks to 16 years) with ARI (emergency department visits for croup and hospitalizations for croup, asthma, bronchiolitis, and pneumonia) between July 1, 2014 and June 30, 2016. Subjects were surveyed upon enrollment for sociodemographics, healthcare utilization, home SHS exposure (0 or ≥1 smoker in the home), and child HRQOL (Pediatric Quality of Life Physical Functioning Scale) for both baseline health (preceding illness) and acute illness (on admission). Data on insurance status and medical complexity were collected from the Pediatric Hospital Information System database. Multivariable linear mixed regression models examined associations between SHS exposure and HRQOL.

RESULTS

Home SHS exposure was reported in 728 (32%) of the 2,309 included children. Compared with nonexposed children, SHS-exposed children had significantly lower HRQOL scores for baseline health (mean difference -3.04 [95% CI -4.34, -1.74]) and acute illness (-2.16 [-4.22, -0.10]). Associations were strongest among children living with two or more smokers. HRQOL scores were lower among SHS-exposed children for all four conditions but only significant at baseline for bronchiolitis (-2.94 [-5.0, -0.89]) and pneumonia (-4.13 [-6.82, -1.44]) and on admission for croup (-5.71 [-10.67, -0.75]).

CONCLUSIONS

Our study demonstrates an association between regular SHS exposure and decreased HRQOL with a dose-dependent response for children with ARI, providing further evidence of the negative impact of SHS.

Assessing pediatric tobacco exposure using parent report: comparison with hair nicotine

INTRODUCTION

The purpose of this study was to examine the relationships between screening questions for secondhand smoke (SHS) exposure and biomarker results using hair nicotine levels. Our ultimate goal was to develop sensitive and valid screening tools in pediatric clinical settings for SHS exposure.

METHODS

Investigators developed a core set of questions regarding exposure. Data from two separate ongoing studies of well children and those with bronchopulmonary dysplasia (BPD) were used to assess the concordance between responses and hair nicotine levels. Sensitivity, a positive predictive value, and accuracy were examined.

RESULTS

There was no single question with similar sensitivity in both populations. The question with the highest positive predictive value (90.8% well-cohort and 84.6% BPD cohort) for both the groups was whether the child had been exposed to in-home smoking in the last 7 days. The question with the highest accuracy for both groups was the number of smokers at home (0 vs ≥ 1), with an accuracy of 72.4% for well children and 79.0% for the BPD cohort.

CONCLUSIONS

There was a wide variability in the performance of specific questions. These data demonstrate that a "one-size-fits-all" approach to screening for secondhand tobacco smoke exposure may not be appropriate for all pediatric populations.

Secondhand smoke exposure, illness severity, and resource utilization in pediatric emergency department patients with respiratory illnesses

OBJECTIVE

Hospital-based data reveal that children who have secondhand smoke exposure (SHSe) experience severe respiratory illnesses and greater resource utilization. Our objective was to assess the relationship between SHSe and illness severity/resource utilization among children presenting to the pediatric emergency department (PED) with three common respiratory conditions-asthma, bronchiolitis, and pneumonia.

METHODS

A retrospective review of a yearlong consecutive sample of PED patients with SHSe status documentation and asthma, bronchiolitis, or pneumonia diagnoses was performed. PED illness severity/resource utilization variables included triage categorization, initial oxygen saturation, evaluation/testing (influenza A & B, respiratory syncytial virus, chest X-ray), procedures/interventions performed (supplemental oxygen, suctioning, intubation), medications administered, and disposition. Logistic and linear regression models were conducted to determine differences in each diagnosis group while controlling for sociodemographics, medical history, seasonality, and insurance type.

RESULTS

There were 3,229 children with documentation of SHSe status and an asthma (41%), bronchiolitis (36%), or pneumonia (23%) diagnosis. Across diagnosis groups, approximately 1/4 had positive documentation of SHSe. Asthmatic children with SHSe were more likely to receive corticosteroids (odds ratio (OR) = 1.71, 95% confidence interval (CI) = 1.19, 2.44) and/or magnesium sulfate (OR = 1.66, 95% CI = 1.14, 2.40). Children with SHSe and bronchiolitis were more likely to receive racemic epinephrine (OR = 2.48, 95% CI = 1.21, 5.08), have a chest X-ray (OR = 1.36, 95% CI = 1.00, 1.85), and/or be admitted (OR = 1.46, 95% CI = 1.09, 1.95). No differences in illness severity/resource utilization were identified for children with pneumonia.

CONCLUSIONS

SHS-exposed children with asthma or bronchiolitis have greater illness severity/resource utilization. Our findings highlight the importance of SHSe assessment, cessation, and research efforts in the PED setting.

Secondhand Smoke Exposure and Pediatric Healthcare Visits and Hospitalizations

INTRODUCTION

This study assessed the relationship between secondhand smoke exposure (SHSe) as measured by serum cotinine and healthcare utilization among children.

METHODS

In 2016, the 2009-2012 National Health and Nutrition Examination Survey data were analyzed including 4,985 children aged 3-19 years. Associations between SHSe and having a routine place for healthcare, type of place, and hospital utilization were examined using logistic regression models. Poisson regression analyses assessed the relationship between SHSe and number of hospital admissions. Relationships between SHSe and acute care visits and hospital utilization were examined among asthmatic children.

RESULTS

SHSe level did not differ by having a routine place for healthcare, although children with high SHSe indicative of active smoking (cotinine ≥3 ng/mL) were 3.49 times (95% CI=1.77, 6.89) more likely to use an emergency department. Children with high SHSe were 2.85 times (95% CI=1.87, 4.34) more likely to have had an overnight hospital stay. Children with high SHSe had 2.05 times (95% CI=1.46, 2.87) the risk of having a higher number of hospital admissions for overnight stays versus children with no SHSe (cotinine <0.05 ng/mL). Among asthmatic children, those with high SHSe and low SHSe (cotinine 0.05-2.99 ng/mL) were more likely to have an acute care visit, overnight hospital stay, and higher number of hospital admissions than asthmatic children with no SHSe.

CONCLUSIONS

High SHSe is associated with increased healthcare utilization. The emergency department and inpatient settings are important venues in which to routinely offer cessation and SHSe reduction interventions.

The association between environmental tobacco smoke exposure and childhood respiratory disease: a review

INTRODUCTION

Childhood respiratory illness is a major cause of morbidity and mortality particularly in low and middle-income countries. Environmental tobacco smoke (ETS) exposure is a recognised risk factor for both acute and chronic respiratory illness. Areas covered: The aim of this paper was to review the epidemiology of ETS exposure and impact on respiratory health in children. We conducted a search of 3 electronic databases of publications on ETS and childhood respiratory illness from 1990-2015. Key findings were that up to 70% of children are exposed to ETS globally, but under-reporting may mask the true prevalence. Maternal smoking and ETS exposure influence infant lung development and are associated with childhood upper and lower respiratory tract infection, wheezing or asthma. Further, exposure to ETS is associated with more severe respiratory disease. ETS exposure reduces lung function early in life, establishing an increased lifelong risk of poor lung health. Expert commentary: Urgent and effective strategies are needed to decrease ETS exposure in young children to improve child and long-term lung health in adults especially in low and middle income countries where ETS exposure is increasing.

Passive smoking and influenza-like illness in housewives: A perspective of gene susceptibility

Relation between influenza-like illness (ILI) and passive smoking remains a debate of subject. We aimed to determine an association of passive smoking with ILI risk of housewives in North China, and the modification effects of gene polymorphisms related to the metabolisms of smoking pollutants. We included 379 housewives for a cross-sectional study in Shanxi Province, China, including 118 with ILI frequency of "≥1 times per year" as the case group and 261 with ILI frequency of "<1 time per year" in the past 10 years as the control group. We collected their information on frequencies of passive smoking and ILI by questionnaires, as well as their single nucleotide polymorphisms (SNPs) of genes related to Phase I and Phase II metabolisms of smoking pollutants. Our results revealed a significant Spearman correlation between frequencies of ILI and passive smoking (r = 0.406, p < 0.001). Frequency of passive smoking was associated with an increased risk of ILI with adjusted OR [6.75 (95% confidence interval: 3.98-11.4)]. Dose-response association between the passive smoking and ILI risk was observed with or without adjusting for confounders. Mutant types of rs1041983 (N-acetyltransferase 2 gene, NAT2) had a synergetic effect with passive smoking on ILI frequency, while mutant types of rs1695 (glutathione S-transferase P1 gene, GSTP1) had an antagonistic effect. Overall, our study results supported the hypothesis that passive smoking was positively associated with ILI frequency in housewives and this effect was modified by gene polymorphisms of Phase II metabolism genes (NAT2 and GSTP1).

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.

Risk Factors for Influenza A(H7N9) Disease in China, a Matched Case Control Study, October 2014 to April 2015

Background. Human infections with avian influenza A(H7N9) virus have been associated with exposure to poultry and live poultry markets (LPMs). We conducted a case-control study to identify additional and more specific risk factors.

Methods. Cases were laboratory-confirmed A(H7N9) infections in persons in China reported from October 1, 2014 to April 30, 2015. Poultry workers, those with insufficient data, and those refusing participation were excluded. We matched up to 4 controls per case by sex, age, and residential community. Using conditional logistic regression, we examined associations between A(H7N9) infection and potential risk factors.

Results. Eighty-five cases and 334 controls were enrolled with similar demographic characteristics. Increased risk of A(H7N9) infection was associated with the following: visiting LPMs (adjusted odds ratio [aOR], 6.3; 95% confidence interval [CI], 2.6–15.3), direct contact with live poultry in LPMs (aOR, 4.1; 95% CI, 1.1–15.6), stopping at a live poultry stall when visiting LPMs (aOR, 2.7; 95% CI, 1.1–6.9), raising backyard poultry at home (aOR, 7.7; 95% CI, 2.0–30.5), direct contact with backyard poultry (aOR, 4.9; 95% CI, 1.1–22.1), and having ≥1 chronic disease (aOR, 3.1; 95% CI, 1.5–6.5).

Conclusions. Our study identified raising backyard poultry at home as a risk factor for illness with A(H7N9), suggesting the need for enhanced avian influenza surveillance in rural areas.

Influenza A virus infection and cigarette smoke impair bronchodilator responsiveness to β-adrenoceptor agonists in mouse lung

β2-adrenoceptor agonists are the mainstay therapy for patients with asthma but their effectiveness in cigarette smoke (CS)-induced lung disease such as chronic obstructive pulmonary disease (COPD) is limited. In addition, bronchodilator efficacy of β2-adrenoceptor agonists is decreased during acute exacerbations of COPD (AECOPD), caused by respiratory viruses including influenza A. Therefore, the aim of the present study was to assess the effects of the β2-adrenoceptor agonist salbutamol (SALB) on small airway reactivity using mouse precision cut lung slices (PCLS) prepared from CS-exposed mice and from CS-exposed mice treated with influenza A virus (Mem71, H3N1). CS exposure alone reduced SALB potency and efficacy associated with decreased β2-adrenoceptor mRNA expression, and increased tumour necrosis factor α (TNFα) and interleukin-1β (IL-1β) expression. This impaired relaxation was restored by day 12 in the absence of further CS exposure. In PCLS prepared after Mem71 infection alone, responses to SALB were transient and were not well maintained. CS exposure prior to Mem71 infection almost completely abolished relaxation, although β2-adrenoceptor and TNFα and IL-1β expression were unaltered. The present study has shown decreased sensitivity to SALB after CS or a combination of CS and Mem71 occurs by different mechanisms. In addition, the PCLS technique and our models of CS and influenza infection provide a novel setting for assessment of alternative bronchodilators.

Altered expression of the CCN genes in the lungs of mice in response to cigarette smoke exposure and viral and bacterial infections

The CCN proteins are key signaling and regulatory molecules involved in many biological functions and contribute to malignant and non-malignant lung diseases. Despite the high morbidity and mortality of the lung respiratory infectious diseases, there is very little data related to the expression of the CCNs during infection. We investigated in mice the pulmonary mRNA expression levels of five CCNs (1 to 5) in response to influenza A virus (IAV) and bacterial agents (Nontypeable Haemophilus influenzae (NTHi), lipopolysaccharide (LPS) and lipoteichoic acid (LTA)). IAV, NTHi, LPS or LTA were instilled intranasally into mice. Mice were also exposed for 4days or 8weeks to cigarette smoke alone or prior infection to IAV in order to determine if CS modifies the CCN response to a viral infection. All challenges induced a robust inflammation. The mRNA expression of CCN1, CCN2 and CCN3 was decreased after short exposure to CS whereas prolonged exposure altered the expression of CCN1, CCN3 and CCN4. Influenza A virus infection increased CCN1, 2, 4 and 5 mRNA levels but expression of CCN3 was significantly decreased. Acute CS exposure prior infection had little effect on the expression of CCN genes but prolonged exposure abolished the IAV-dependent induction. Treatment with LPS or LTA and infection with NTHi revealed that both Gram-positive and Gram-negative bacteria rapidly modulate the expression of the CCN genes. Our findings reveal that several triggers of lung inflammation influence differently the CCN genes. CCN3 deserves special attention since its mRNA expression is decreased by all the triggers studied.

Regulation of Retinoic Acid Receptor Beta by Interleukin-15 in the Lung during Cigarette Smoking and Influenza Virus Infection

Virus-induced exacerbations often lead to further impairment of lung function in chronic obstructive pulmonary disease. IL-15 is critical in antiviral immune responses. Retinoic acid (RA) signaling plays an important role in tissue maintenance and repair, particularly in the lung. We studied RA signaling and its relation to IL-15 in the lung during cigarette smoke (CS) exposure and influenza virus infection. In vivo studies show that RA signaling is diminished by long-term CS exposure or influenza virus infection alone, which is further attenuated during infection after CS exposure. RA receptor β (RARβ) is specifically decreased in the lung of IL-15 transgenic (overexpression; IL-15Tg) mice, and a greater reduction in RARβ is found in these mice compared with wild-type (WT) mice after infection. RARβ is increased in IL-15 knockout (IL-15KO) mice compared with WT mice after infection, and the additive effect of CS and virus on RARβ down-regulation is diminished in IL-15KO mice. IL-15 receptor α (IL-15Rα) is increased and RARβ is significantly decreased in lung interstitial macrophages from IL-15Tg mice compared with WT mice. In vitro studies show that IL-15 down-regulates RARβ in macrophages via IL-15Rα signaling during influenza virus infection. These studies suggest that RA signaling is significantly diminished in the lung by CS exposure and influenza virus infection. IL-15 specifically down-regulates RARβ expression, and RARβ may play a protective role in lung injury caused by CS exposure and viral infections.

Impact of Tobacco Smoke and Nicotine Exposure on Lung Development

Tobacco smoke and nicotine exposure during prenatal and postnatal life can impair lung development, alter the immune response to viral infections, and increase the prevalence of wheezing during childhood. The following review examines recent discoveries in the fields of lung development and tobacco and nicotine exposure, emphasizing studies published within the last 5 years. In utero tobacco and nicotine exposure remains common, occurring in approximately 10% of pregnancies within the United States. Exposed neonates are at increased risk for diminished lung function, altered central and peripheral respiratory chemoreception, and increased asthma symptoms throughout childhood. Recently, genomic and epigenetic risk factors, such as alterations in DNA methylation, have been identified that may influence the risk for long-term disease. This review examines the impact of prenatal tobacco and nicotine exposure on lung development with a particular focus on nicotinic acetylcholine receptors. In addition, this review examines the role of prenatal and postnatal tobacco smoke and nicotine exposure and its association with augmenting infection risk, skewing the immune response toward a T-helper type 2 bias and increasing risk for developing an allergic phenotype and asthmalike symptoms during childhood. Finally, this review outlines the respiratory morbidities associated with childhood secondhand smoke and nicotine exposure and examines genetic and epigenetic modifiers that may influence respiratory health in infants and children exposed to in utero or postnatal tobacco smoke.

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.

Secondhand Smoke Exposure and Illness Severity among Children Hospitalized with Pneumonia

OBJECTIVE

To assess the relationship between secondhand smoke (SHS) exposure and disease severity among children hospitalized with community-acquired pneumonia (CAP).

STUDY DESIGN

Children hospitalized with clinical and radiographic CAP were enrolled between January 1, 2010, and June 30, 2012 at 3 hospitals in Tennessee and Utah as part of the Centers for Disease Control and Prevention's Etiology of Pneumonia in the Community study. Household SHS exposure was defined based on the number of smokers in the child's home. Outcomes included hospital length of stay, intensive care unit admission, and mechanical ventilation. Proportional hazards and logistic regression models were used to assess associations between SHS exposure and outcomes. All models were adjusted for age, sex, race/ethnicity, household education level, government insurance, comorbidities, enrollment site, year, and season.

RESULTS

Of the 2219 children included in the study, SHS exposure was reported in 785 (35.4%), including 325 (14.8%) with ≥2 smokers in the home. Compared with nonexposed children, the children exposed to ≥2 smokers had longer length of stay (median, 70.4 hours vs 64.4 hours; adjusted hazard ratio, 0.85; 95% CI, 0.75-0.97) and were more likely to receive intensive care (25.2% vs 20.9%; aOR, 1.44; 95% CI, 1.05-1.96), but not mechanical ventilation. Outcomes in children exposed to only 1 household smoker were similar to those in nonexposed children.

CONCLUSION

Children hospitalized with CAP from households with ≥2 smokers had a longer length of stay and were more likely to require intensive care compared with children from households with no smokers, suggesting that they experienced greater pneumonia severity.

Severe asthma in school-age children: evaluation and phenotypic advances

Although the majority of children with asthma have a favorable clinical response to treatment with low to moderate doses of inhaled corticosteroids (ICS), a small subset of children have "severe" asthma characterized by ongoing symptoms and airway inflammation despite treatment with high doses of ICS and even oral corticosteroids. Although there is symptom heterogeneity in the affected children, children with severe asthma share the risk for adverse outcomes, including recurrent and potentially life-threatening exacerbations, which contribute to substantial economic burden. This article reviews current knowledge of severe asthma in school-age children (age 6-17 years) with a focus on recent literature published after January 2012. Clinical management approaches for children with severe asthma are discussed as well as current phenotyping efforts and emerging phenotypic-directed therapies that may be of benefit for subpopulations of children with severe asthma in the future.

Effect of broccoli sprouts on nasal response to live attenuated influenza virus in smokers: a randomized, double-blind study

BACKGROUND

Smokers have increased susceptibility and altered innate host defense responses to influenza virus infection. Broccoli sprouts are a source of the Nrf2 activating agentsulforaphane, and short term ingestion of broccoli sprout homogenates (BSH) has been shown to reduce nasal inflammatory responses to oxidant pollutants.

OBJECTIVES

Assess the effects of BSH on nasal cytokines, virus replication, and Nrf2-dependent enzyme expression in smokers and nonsmokers.

METHODS

We conducted a randomized, double-blind, placebo-controlled trial comparing the effects of BSH on serially sampled nasal lavage fluid (NLF) cytokines, viral sequence quantity, and Nrf2-dependent enzyme expression in NLF cells and biopsied epithelium. Healthy young adult smokers and nonsmokers ingested BSH or placebo (alfalfa sprout homogenate) for 4 days, designated Days -1, 0, 1, 2. On Day 0 they received standard vaccine dose of live attenuated influenza virus (LAIV) intranasally. Nasal lavage fluids and nasal biopsies were collected serially to assess response to LAIV.

RESULTS

In area under curve analyses, post-LAIV IL-6 responses (P = 0.03) and influenza sequences (P = 0.01) were significantly reduced in NLF from BSH-treated smokers, while

NAD(P)H

quinoneoxidoreductasein NLF cells was significantly increased. In nonsmokers, a similar trend for reduction in virus quantity with BSH did not reach statistical significance.

CONCLUSIONS

In smokers, short term ingestion of broccoli sprout homogenates appears to significantly reduce some virus-induced markers of inflammation, as well as reducing virus quantity. Nutritional antioxidant interventions have promise as a safe, low-cost strategy for reducing influenza risk among smokers and other at risk populations.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01269723.

Influenza virus-induced lung inflammation was modulated by cigarette smoke exposure in mice

Although smokers have increased susceptibility and severity of seasonal influenza virus infection, there is no report about the risk of 2009 pandemic H1N1 (pdmH1N1) or avian H9N2 (H9N2/G1) virus infection in smokers. In our study, we used mouse model to investigate the effect of cigarette smoke on pdmH1N1 or H9N2 virus infection. Mice were exposed to cigarette smoke for 21 days and then infected with pdmH1N1 or H9N2 virus. Control mice were exposed to air in parallel. We found that cigarette smoke exposure alone significantly upregulated the lung inflammation. Such prior cigarette smoke exposure significantly reduced the disease severity of subsequent pdmH1N1 or H9N2 virus infection. For pdmH1N1 infection, cigarette smoke exposed mice had significantly lower mortality than the control mice, possibly due to the significantly decreased production of inflammatory cytokines and chemokines. Similarly, after H9N2 infection, cigarette smoke exposed mice displayed significantly less weight loss, which might be attributed to lower cytokines and chemokines production, less macrophages, neutrophils, CD4⁺ and CD8⁺ T cells infiltration and reduced lung damage compared to the control mice. To further investigate the underlying mechanism, we used nicotine to mimic the effect of cigarette smoke both in vitro and in vivo. Pre-treating the primary human macrophages with nicotine for 72 h significantly decreased their expression of cytokines and chemokines after pdmH1N1 or H9N2 infection. The mice subcutaneously and continuously treated with nicotine displayed significantly less weight loss and lower inflammatory response than the control mice upon pdmH1N1 or H9N2 infection. Moreover, α7 nicotinic acetylcholine receptor knockout mice had more body weight loss than wild-type mice after cigarette smoke exposure and H9N2 infection. Our study provided the first evidence that the pathogenicity of both pdmH1N1 and H9N2 viruses was alleviated in cigarette smoke exposed mice, which might partially be attributed to the immunosuppressive effect of nicotine.

High cotinine levels are persistent during the first days of life in newborn second hand smokers

BACKGROUND

Despite the adverse effects of maternal smoking during pregnancy on the newborn's health are well-known, in the pediatric population, a high prevalence exists that is very much affected by second hand smoke (SHS). This study aims to investigate the impact of maternal smoking habits during pregnancy on cotinine levels in newborns during the first days of life. The high association between cotinine concentration in maternal and umbilical cord blood (UCB) has been previously reported, but the levels of blood cotinine that remain in infants born to smokers is unknown.

METHODS

Cotinine concentration was measured in UCB, in maternal and newborn peripheral blood. Data from UCB sample dyads of ninety mothers and from seventy-one newborns were analyzed.

RESULTS

Cotinine levels were significantly different among non-smokers (9.9 ± 5.9 ng/ml), moderate (67.3 ± 7.4 ng/ml), and heavy smokers (137.7 ± 19.5 ng/ml) (p<0.0001). Significant correlations were found between maternal and UCB cotinine (r=0.748; p<0.001), and between UCB and newborn plasma cotinine at 48 h after birth (r=0.541; p<0.001). The smokers exposed their infants to cotinine with a median of 31.7 ± 8.6 ng/ml (moderate) or 59.1 ± 13.3 ng/ml (heavy smokers) until at least, 48 h after birth. Reduced birth weight and length were significantly related with UCB cotinine levels.

CONCLUSIONS

A positive association between UCB and plasmatic cotinine in newborns was found. The high cotinine levels detected in newborns from smoker mothers indicates that their infants are subjected to elevated SHS from birth. These results can help to reinforce the awareness of the adverse effects of smoking during pregnancy.

The relationship between cotinine concentrations and inflammatory markers among highly secondhand smoke exposed non-smoking adolescents

BACKGROUND

Secondhand smoke (SHS) exposure is a risk factor of respiratory, cardiovascular and inflammatory diseases, however its association with inflammatory markers among highly SHS exposed adolescents has not yet been explored.

METHODS

Participants included in this study were a subset of 68 non-smoking adolescents, aged 12.5-17.5 from the Healthy Lifestyle in Europe by Nutrition in Adolescence (HELENA) study, recruited from Crete Greece. Smoking and SHS exposure was assessed via serum cotinine concentrations. Cytokines (Interleukin-1β, 2, 4, 5 and 6, tumor necrosis factor-α, interferon-γ, tumor growth factor-β1), immunoglobulins IgG, IgA, IgM, complement factors C3, C4, high sensitivity C-reactive protein, and endothelial inflammatory markers [soluble E-selectin, soluble L-selectin, soluble intercellular adhesion molecules (sICAM-1) and soluble vascular cell adhesion molecules-1 (sVCAM-1)] were assessed. Inflammatory markers in the lower 25th percentile and upper 75th percentile groups of cotinine levels were compared and multivariate linear regression analysis was performed controlling for age, sex and BMI.

RESULTS

Cotinine concentrations were notably elevated (geometric mean 0.82ng/ml, 95%CI 0.62-1.07) in this study population. A significant decrease in IL-4 (130.09 vs. 25.77pg/ml, p=0.014) and IL-6 (19.52 vs. 5.52pg/ml, p=0.008) concentrations between the upper 75th percentile cotinine level group and lower 25th percentile cotinine level group was observed. In a multivariate linear regression analysis, cotinine concentrations had a weak inverse association with IL-4 and IL-6 (p=0.028 and p=0.06) which was not statistically significant when adjusted for multiple comparisons (modified Bonferroni, p>0.016). No differences in the other variables was noted.

CONCLUSIONS

Among highly SHS exposed adolescents, cotinine levels had weak inverse association with IL-4 and IL-6, which did not achieve statistical significance. However, our results potentially indicate an immunosuppressive role of SHS. Further research is warranted to explore this hypothesis.

Racial, Ethnic, and Language Disparities in Children's Exposure to Secondhand Smoke

Race and ethnicity affect children's risk of secondhand smoke exposure. However, little is known about how race and language preference impact parents' self-reported smoking and stopping smoking rates. We analyzed data for 16,523 children aged 0-11 years from a pediatric computer decision support system (Child Health Improvement through Computer Automation [CHICA]). CHICA asks families in the waiting room about household smokers. We examined associations between race, insurance, language preference, and household smoking and reported stopping smoking rates using logistic regression. Almost a quarter (23%) of the children's families reported a smoker at home. Hispanic children are least likely (odds ratio [OR]: 0.17, confidence interval [CI]: 0.12-0.24) to have secondhand smoke exposure when compared to African American and white children, as were those with private insurance (OR: 0.52, CI: 0.43-0.64) or no insurance (OR: 0.79, CI: 0.71-0.88) compared to publicly insured. Children from English speaking families were more likely (OR: 1.55, CI: 1.24-1.95) to have secondhand smoke exposure compared to Spanish speaking families. Among smoking families, 30% reported stopping smoking subsequently. Stopping rates were higher in Hispanic (OR: 3.25, CI: 2.06-5.13) and African American (OR: 1.39, CI: 1.01-1.91) families compared to white children's families. Uninsured families were less likely than publicly insured families to report stopping smoking (OR: 0.76, CI: 0.63-0.92). English speaking families were less likely (OR: 0.56, CI: 0.41-0.75) to report stopping smoking compared to Spanish speaking even in a subgroup analyses of Hispanic families (OR: 0.55, CI: 0.39-0.76). In our safety net practices serving children predominantly on public insurance, Spanish speaking families reported the lowest risk of secondhand smoke exposure in children and the highest rate of stopping smoking in the household. Hispanic families may have increasing secondhand exposure and decreasing rates of stopping smoking as they acculturate.

Tobacco or healthy children: the two cannot co-exist

Tobacco exposure increases mortality and morbidity of the fetus, the child, the adolescent, and their children in turn. Nearly half the children in the world are exposed. Smoking is not merely personal choice or personal responsibility; those subtle phrases undermine those who have no choice in the matter. Tobacco control must take a multi-pronged attack. Smoking cessation by adults in childbearing years must take center stage of these efforts, because it is the only way to ensure a smoke-free environment for children. Smoke-free parents provide a role model for smoke-free young people, and erode the image of smoking as a desirable adult behavior to emulate. Pediatricians and pediatric pulmonologists have a key role to play here. This goal will reduce morbidity and mortality among adults and children. Legislation regarding taxation, environments, tobacco constituents, product placement and display, packaging, and media education are all key to this core goal. Smoke-free policy must be protected from attack based on trade agreements. Research is needed into more effective ways to attract and help people give up smoking, and into educating and re-deploying tobacco industry workers in emerging and developed countries.