Effect of environmental tobacco smoke on cough in children with a history of tonsillectomy or adenoidectomy

Impact of environmental tobacco smoke exposure on anaesthetic and surgical outcomes in children: a systematic review and meta-analysis

BACKGROUND

Tobacco smoke exposure in adults is linked to adverse anaesthetic and surgical outcomes. Environmental tobacco smoke (ETS) exposure, including passive smoking, causes a number of known harms in children, but there is no established evidence review on its impact on intraoperative and postoperative outcomes.

OBJECTIVES

To undertake a systematic review of the impact of ETS on the paediatric surgical pathway and to establish if there is evidence of anaesthetic, intraoperative and postoperative harm.

ELIGIBILITY CRITERIA PARTICIPANTS

Children aged 0-18 years undergoing anaesthetic or surgical procedures, any country, English language papers.

EXPOSURE

ETS exposure assessed via questioning, observation or biological marker.

OUTCOME MEASURES

Frequency of respiratory and other adverse events during anaesthesia, surgery and recovery, and longer term surgical outcomes.

RESULTS

28 relevant studies were identified; 15 considered anaesthetic outcomes, 12 surgical outcomes, and 1 a secondary outcome. There was sufficient evidence to demonstrate that environmental smoke exposure significantly increased risk of perianaesthetic respiratory adverse events (Pooled risk ratio 2.52 CI 95% 1.68 to 3.77), and some evidence that ear and sinus surgery outcomes were poorer for children exposed to ETS.

CONCLUSIONS

ETS exposure increases the risk of anaesthetic complications and some negative surgical outcomes in children, and this should be considered when planning surgery. Research is required to demonstrate whether changes in household smoking behaviour prior to surgery reduces risk of adverse outcomes, and to close the evidence gap around other outcomes such as wound healing and respiratory infections.

TRIAL REGISTRATION NUMBER

Review registration number 42014014557.

Cost Analysis of Motivational Interviewing and Preschool Education for Secondhand Smoke Exposures

INTRODUCTION

This study determines if expenditures associated with implementing a combined motivational interviewing (MI) and Head Start-level education program (MI+Education), as compared to education alone, yield cost savings to society.

METHODS

Post hoc cost analyses were applied to a randomized controlled-trial of MI among predominantly African American, low-income caregivers of 330 Baltimore City Head Start students who reside with a smoker. The primary outcome was the cost savings of MI+Education from averted direct secondhand smoke exposure (SHSe)-related acute healthcare events and inferred indirect costs (work days lost, transportation and reduction in cigarettes smoked). The net direction of savings was defined by the sum of averted direct and indirect costs of the MI+Education intervention at 3, 6 and 12 months, benchmarked against the Education alone cohort at the equivalent time periods.

RESULTS

The costs saved by the MI+Education intervention, relative to Education alone, resulted in savings at solely the 12-month follow-up time point. Significant savings were appreciated from averted emergency department (ED) visits at 12 months ($4410; 95% simulation interval [SI]: $2241, $6626) for the MI+Education group. The total savings at 12 months ($2274; 95% SI: -3916, $8442) could not overcome additional program costs of implementing MI to Head Start-level education ($13 695; 95% SI: $11 250, $16 034).

CONCLUSIONS

This study is the first to examine the cost of either intervention on SHSe-attributed pediatric healthcare costs from a population level relevant for federal and community decision makers. Intervention costs could not be offset by short-term savings but a trend towards positive savings was appreciated 1 year after implementation.

IMPLICATIONS

Behavioral interventions are effective in reducing SHSe in children. However, many of these interventions are not implemented in community settings due to lack of resources and money. Behavioral strategies may be a cost-saving addition to the national initiatives to create smoke-free home environments. The long-term benefits of MI, as evidenced from cost savings from averted ED visits, appeared to show MI+Education to be a robust long-term strategy. The decrease of acute healthcare services at 12 months may be informative for policy decision makers seeking to allocate limited resources to reduce the usage of costly ED services and hospital readmissions.

Cigarette Smoke Inhibits Dynamic Ciliary Beat Frequency in Pediatric Adenoid Explants

Objective. Environmental tobacco smoke exposure in children increases the incidence of upper respiratory infections, chronic sinusitis, and chronic otitis media. This study investigated the effects of ex vivo and in vitro smoke exposure on dynamic ciliary beat frequency (CBF) in pediatric adenoid explants.

Study Design. Blinded and controlled prospective study.

Setting. Tertiary care pediatric hospital.

Subjects and Methods. Fifty-five children undergoing adenoidectomy for obstructive sleep apnea and adenotonsillar hypertrophy were enrolled in this study. Adenoids were surgically removed using currettage. Hair was collected for nicotine analysis. Tissue was sectioned into 1-mm strips and allowed to equilibrate in DMEM/F12 with 2% fetal bovine serum for 24 hours. Cilia-bearing explant tissues were treated with either DMEM/F12 media, 5% cigarette smoke extract (CSE), or 10% CSE for 24 hours. Cilia were then stimulated using either isoproterenol (10−9 M) or methacholine (10−6M), and CBF was serially recorded using the Sisson-Ammons Video Analysis (SAVA) software.

Results. Children with hair nicotine levels ≥1 ng/mg consistent with secondhand smoke exposure display blunted dynamic CBF response ex vivo. Explants incubated with CSE in vitro demonstrate significant impairment of isoproterenol and methacholine-induced CBF.

Conclusion. CBF of adenoid explants increases when stimulated with isoproterenol and methacholine. Ex vivo and in vitro smoke exposure blunted ciliostimulation of CBF in adenoid explants. Smoke exposure impairs ciliary function in the pediatric airway and could potentially contribute to disorders such as chronic rhinosinusitis and chronic otitis media.

Environmental tobacco smoke exposure and respiratory morbidity in children

Environmental tobacco smoke (ETS) contains carcinogenic and toxic agents. Smoking might have a more serious effect on children than adults. We aimed to examine the effects of passive smoking on pulmonary function and respiratory health in children and to assess the concordance between parental self-reported smoking habits and urinary cotinine levels in their children. This cross-sectional study was conducted in the winter with the participation of 131 children (9-12 yr old). The procedure for each subject consisted of administration of a questionnaire to the parents, and collection of a urine sample and measurement of lung function in each child. Cotinine level excreted into urine was analyzed with respect to parental self-reported smoking behavior. Working mothers and mothers with higher level of education tended to smoke more at home (p values, respectively, .002 and .005). There was a statistical difference between the urinary cotinine levels of children when divided into two groups according to their fathers' smoking behavior at home (p = .0001). No statistically significant difference was determined in the mean episodes of respiratory infections treated during the last 12 mo among the groups formed according to daily number of cigarettes smoked by the parents at home (1: not exposed; 2: < 5 cigarettes; 3: 5-10 cigarettes; 4: > 10 cigarettes), or among the groups formed according to urinary cotinine levels (1: < 10 ng/ml; 2: > or =10 ng/ml). No significant difference was demonstrated in any of the respiratory function parameters investigated between the groups considered. The reliability of the declarations of the parents in the estimation of ETS exposure of children was low. Children are unable to remove themselves from ETS exposure. It is better to reduce the percentage of parents who smoke rather than to isolate smokers or increase ventilation.

Environmental tobacco smoke exposure in school children: parent report and urine cotinine measures

BACKGROUND

Environmental tobacco smoke (ETS) in the home continues to be a major health risk for children around the world. Measuring ETS is a central feature of clinical and epidemiological studies, with children's exposure often assessed through parental estimates. The authors examined the relationship between parent-reported estimates of children's exposure to ETS and children's urinary cotinine levels and evaluated the ETS exposure and its effect on respiratory health in children.

METHODS

A total of 188 school children were included in the study. Parents were asked to complete a questionnaire about their smoking habits, their children's respiratory morbidity status and housing conditions. Urinary cotinine levels were measured in children.

RESULTS

According to the responses, 72.3% of the children came from households with smokers, and 34.6% had daily exposure to ETS. When urine cotinine levels of >10 ng/mL were used as the yardstick of exposure, 76% of the children were identified as ETS exposed. No relation was detected between the symptoms of respiratory tract diseases and ETS exposure. To determine the amount of ETS exposure, the contribution of parental reports was low.

CONCLUSION

To evaluate the level of ETS exposure of children, the parents' reports were not reliable. The addition of a biological measure results in a more informative estimate of ETS exposure in children.

The effect of parental smoking on lung function and development during infancy

While the adverse effects of parental smoking on respiratory health during childhood are well recognized, its potential impact on early lung development is less clear. This review summarizes current evidence on the effect of parental smoking on lung function during infancy. It is difficult to separate the effects of pre- and postnatal exposure, since the majority of mothers who smoke in pregnancy (currently around 30% worldwide) continue to do so thereafter. Nevertheless, measurements undertaken prior to any postnatal exposure have consistently demonstrated significant changes in tidal flow patterns in infants whose mothers smoked in pregnancy. While there is, as yet, no convincing evidence from studies in human infants that smoking during pregnancy is associated with increased airway responsiveness at birth, many studies have demonstrated a reduction in forced expiratory flows (on average by 20%) in infants exposed to parental smoking. While maternal smoking during pregnancy remains the most significant source of such exposure and is likely to be responsible for diminished airway function in early life, continuing postnatal tobacco smoke exposure will increase the risk of respiratory infections, the combination of both being responsible for the two- to fourfold increased risk of wheezing illnesses observed during the first year of life in infants whose parents smoke. These findings emphasize the need to keep infants in a smoke-free environment both before and after birth, not least because of growing awareness that airway function in later life is largely determined by that during foetal development and early infancy.

Acute upper airway infections

Upper respiratory tract infections are common and important. Although rarely fatal, they are a source of significant morbidity and carry a considerable economic burden. Numerous therapies for the common cold have no effect on symptoms or outcome. Complications such as cough are not improved by over-the-counter preparations, while labelling cough alone as a symptom of asthma may result in unnecessary use of inhaled steroid treatment. Clinical presentation of sore throat does not accurately predict whether the infection is viral or bacterial, while throat culture and rapid antigen tests do not significantly change prescribing practice. Antibiotics have only a limited place in the management of recurrent sore throat due to group A beta-haemolytic streptococcal infection. Routine use of antibiotics in upper respiratory infection enhances parent belief in their effectiveness and increases the likelihood of future consultation in primary care for minor self-limiting illness. Respiratory viruses play a major role in the aetiology of acute otitis media (AOM); prevention includes the use of influenza or RSV vaccination, in addition to reducing other risk factors such as early exposure to respiratory viruses in day-care settings and to environmental tobacco smoke. The use of ventilation tubes (grommets) in secretory otitis media (SOM) remains controversial with conflicting data on developmental outcome and quality of life in young children. New conjugate pneumococcal vaccines appear safe in young children and prevent 6-7% of clinically diagnosed AOM.

The miseries of passive smoking

Passive smoking is defined as an involuntary exposure to a combined but diluted cigarette sidestream smoke (SS, gas and particle phases that are evolved from the smoldering end of a cigarette while the smoker is not puffing) and the exhaled smoke from smokers. SS contains numerous cytotoxic substances such as polycyclic aromatic hydrocarbons (PAHs), aromatic amines, nitrosamines, heavy metals, poisonous gases, pesticide residues, and radioactive elements in quantities much higher than those found from the cigarette mainstream smoke (MS) which is puffed by smokers. Passive smoking is found to be the cause of death from cancers and cardiac disease. Furthermore, it damagingly involves reproductive organs, the nervous system, genetic materials, and is particularly hazardous to mother and child during pregnancy and to those with a history of asthma, chronic infections, induced or earned immune deficiency, or predisposed susceptibility.

The adverse health effects of tobacco and tobacco-related products

Tobacco use continues to occur in epidemic proportions and with it, significant morbidity and mortality. One third of smokers will die prematurely of a smoking-related disease. This article reviews the adverse health effects of tobacco use so that clinicians can be aware of the benefits patients will reap when they stop using this lethal substance.