1. 1 Asthma in Children and Exposure to Environmental Tobacco Smoke in the Home Buddy R. Bates, MSPH Chronic Disease Epidemiology Unit Louisiana Office of Public Health

2. 2 Why is Asthma in Children and ETS Exposure Important? Most Common Chronic Disease among children 1 Estimated 4.8 million (~7%) of children <18 years of age in the U.S. Leading Cause of School Absenteeism, accounting for more than 10 million missed days of school 2 Both asthma prevalence rates and asthma death rates are increasing nationally 3

3. 3 Why is Asthma in Children and ETS Exposure Important? ETS in children is also linked to other respiratory infections, middle ear diseases, SIDS 4,5 Childhood exposure to ETS can lead to asthma in adulthood 6 Children exposed to ETS are more likely to become smokers 6 Parents who smoke 1 pack per day spend approximately $1500.00 per year on cigarettes…this can significantly impact financial status for low income families 7

4. 4 Challenges of Asthma Surveillance.. …it’s not easy…. Until recently, asthma surveillance data at state or local level unavailable Until recently, no standardized definition of asthma Current definition relies on Dr. Dx, or medication use (fails to address undiagnosed asthma No definitive method for diagnosing asthma

5. 5 What Do We Know?..we know that we don’t know much Conflicting Evidence on Asthma Prevalence surveillance methods…. Conflicting data on interventions… Conflicting data on HOME ETS exposure and asthma prevalence

6. 6 Dose Response As ETS exposure increases, Asthma severity increases 8

7. 7 Does the presence of children with history of asthma, or current asthma affect ETS exposure in the home?

8. 8 Does the presence of children with history of asthma, or current asthma affect ETS exposure in the home …nope….

9. 9 Does the presence of children with history of asthma, or current asthma affect ETS exposure in the home Increased levels of parental smoking in the home are associated with a REDUCTION in healthcare contacts for asthma in children with asthma 9

10. 10 Does the presence of children with history of asthma, or current asthma affect ETS exposure in the home *Heavy smokers reduced parent’s awareness of asthma symptoms in children *Heavy smokers may be less concerned about respiratory symptoms *Heavy smokers are more reluctant to take their children to the doctor because they do not wish to be told to stop smoking

11. 11 Nicotine is a drug….. …Buddy’s inflammatory statement…. the opinions expressed here are…

12. 12 What Interventions Work? What influences ETS decisions in the home where a child has asthma?

13. 13 Interventions? Parental Education? …….No Informing parents of the harmful effects of passive smoking was ineffective in persuading them to reduce the exposure of their children to tobacco smoke. Parent’s smoking needs to be addressed as a separate issue from the child’s health 10

14. 14 Interventions? ETS Reduction in the Home?.....No Many common harm reduction strategies such as opening windows, using fans, ionizers, etc…are ineffective 11

15. 15 Interventions? Banning ETS?..…maybe Smoking cessation among household members is the only effective way of reducing passive smoking among children. 11 To date, the evidence on the use and effectiveness of cessation in the home is “limited and confusing”. 11 Banning smoking is associated with a small (but significant) reduction in urinary cotinine levels in infants, whereas, smoking reductions in the home have NO effect on lowering cotinine levels. 11

16. 16 When are Parents Ready to Ban ETS? Unfortunately, Child Hospitalization for Asthma is strongest (but still weak) predictor for Parental cessation 7 Child Hospitalization for asthma may be the prime time for cessation intervention 7

17. 17 METHODS

18. 18 Based on 2002 Louisiana BRFSS Statewide Survey Conducted By Telephone Interview Data is Self-Reported Randomly Selected Adult in Household (may or may not be parent/guardian/head of household)

19. 19 Which Part of BRFSS? Child Asthma Optional Module *Ever and Current Asthma Prevalence Core Tobacco Question *Smoking Status of Respondent (Current, Former,Never) Tobacco Indicators Optional Module *Rules about smoking in the home State Added Question on Tobacco Use *Smoking in home in last 7 days

20. 20 Child Asthma Optional Module Q1: Earlier you said that there were [X#] children aged 17 years or younger living in your household. How many of these children have ever been diagnosed with asthma? Q2: How many of these children still have asthma? (based on CSTE definition..still problematic)

21. 21 Core Tobacco Question Have you smoked at least 100 cigarettes in your lifetime? Do you now smoke every day, some days or not at all?

22. 22 Tobacco Indicators Optional Module Which statement best describes the rules about smoking in your home: –Smoking is not allowed anywhere inside your home –Smoking is allowed in some places or at some times –Smoking is allowed anywhere inside the home –There are no rules about smoking inside the home

23. 23 State Added Tobacco Question During the past week, how many time did anyone, including yourself, smoke cigarettes, cigars, or pipes anywhere inside your home? Note: Although the respondent may be a never or former smoker, that does not imply ETS free environment in home. Those that reported never allowing smoking anywhere, anytime, in their home were excluded (but assumed that no smoking occurred in last 7 days)

24. 24 RESULTS …Asthma surveillance should be one of the core functions of State’s Comprehensive Chronic Disease Programs…

25. 25 Sample Information n=5030 households (with one randomly selected adult in each household) 1,947 households reported having at least one child under the age of 18 43.1% (41.4 - 44.8%) estimated 1,403,714 Households

26. 26 Prevalence of Ever and Current Asthma among Children (ALL household level) 7.5% (6.5 - 8.4%) Ever Asthma of all households have at least one child who has EVER had asthma (240,089 Households) 4.7% (3.9 – 5.4%) Current Asthma of all households have at least one child who has asthma NOW (149,566 Households)

27. 27 Prevalence of Ever Asthma among Children (Among households with children) 17.1% (15.0 – 19.2%) Ever Asthma of all households with at least one child have at least one child who has EVER had asthma (240,089 Households)

28. 28 Ever Asthma Distribution Within Household * Unweighted * Total of 334 Households # of Children Frequency 01555 1288 239 37

29. 29 Prevalence of Current Asthma among Children (Among households with children) 10.7% (9.0 – 12.3%) Current Asthma of all households with at least one child have at least one child who has asthma NOW (149,566 Households)

30. 30 Current Asthma Distribution Within Household * Unweighted * Almost 2/3 ever asthma has current asthma # of Children Frequency 0109 1191 222 35

31. 31 Rules about Smoking in the Home, Smoking Status, and Child Asthma Status

32. 32 Allows Smoking in the Home Ever Asthma Child Never Had Asthma Child Ever Had Asthma Current51.4% (45.5 – 57.4%) 138,629 56.9% (45.1 – 68.6%) 46,075 Former18.5% (12.9 – 24.0%) 30,232 suppressed Never13.8% (11.2 – 16.4%) 93,801 13.8% (7.6 – 20.0%) 17,328

33. 33 Allows Smoking in the Home Current Asthma Child Does Not Have Asthma Now Child Has Asthma Now Current52.1% (46.4 – 57.9%) 159,846 56.6% (42.1 – 71.0%) 24,858 Former18.4% (13.0 – 23.7%) 31,919 suppressed Never14.3% (11.7 – 16.9 %) 103,478 9.2% (3.4 – 15.0%) 7,651

34. 34 Smoking in Home in Last 7 days, Smoking Status, and Child Asthma Status

35. 35 Smoking in the Home in last 7 Days: Ever Asthma Child Never Had Asthma Child Ever Had Asthma Current41.6% (35.8 – 47.4%) 111,191 51.8% (39.4 – 64.1%) 41,235 Former7.1% (3.2 – 11.1%) 11,642 suppressed Never7.4% (5.2 – 9.5%) 50,643 7.2% (2.6 – 11.8%) 8,924

36. 36 Smoking in the Home in last 7 Days: Current Asthma Child Does Not Have Asthma Now Child Has Asthma Now Current42.6% (36.8 – 48.4%) 129,555 53.3% (38.4 – 68.1%) 22,871 Former7.2% (3.4 – 11.0 %) 12,468 suppressed Never7.7% (5.5 – 9.7%) 55,603 4.8% (0.60 – 8.9%) 3,964

37. 37 Conclusions 1 out of 5 households with children in Louisiana have at least one child who has ever had asthma 10% of households with children in Louisiana have at least 1 child who currently has asthma Almost 71,000 households in Louisiana allow smoking where at least one child either has had a history of asthma, or is currently experiencing asthma.

38. 38 Conclusions Current smokers are more likely than Never smokers to allow smoking in the home, regardless of child’s asthma status Within Smoking groups, a child’s asthma status does not affect Rule making regarding smoking in the home

39. 39 Conclusions Current smokers are more likely than Never smokers to have had smoking in the home in the last 7 days Within Smoking groups, a child’s asthma status does not affect whether smoking occurred in the last 7 days

40. 40 Conclusions Target Parents of Asthma Related Children admitted to Emergency Rooms/Hospitals for cessation counseling Offer other parents cessation services based on personal health benefits and not health benefits of children in the home Continue to target children in tobacco use prevention efforts

41. 41 Limitations Self reported (though questions were not bundled together) Lack of info on Asthma severity Lack of direct measurement for ETS exposure in home Lack of direct measurement of ETS in home Lack of information regarding other sources of ETS exposure in children

42. 42 REFERENCES 1)Taylor, WR, Newacheck PW. Impact of Childhood Asthma on Health. Pediatrics 1992: 657-662 2)MMWR 1998; 47 (No SS-1) 3)Cook DG, Strachan DP, Health effects of passive smoking – 10: summary of effects of parental smoking on the respiratory health of children and implications for research. Thorax 1999; 54: 357-366 4)MMWR 1996; 45 (17): 350-353 5)Infante-Rivard C. Childhood asthma and indoor environmental risk factors. Am J Epidemiol 1993; 137: 834- 844 6)Larsson M. et al., Environmental Tobacco Smoke Exposure During Childhood is Associated with Increased Prevalence of Asthma in Adults. Chest; 120:3, 11/2001 7)Winickoff JP. Et al., A smoking cessation intervention for parents of children who are hospitalized for respiratory illness: the Stop Tobacco Outreach Program, Pediatrics, Vol. 111, No. 1, 1/2003 (140-145) 8)Mannino David et al., Involuntary Smoking and Asthma Severity in Children, Chest/122/2/8-2002 9)Crombie IK et al., Does passive smoking increase the frequency of health service contacts in children with asthma? Thorax 2001; 56:9-12 10)Irvine L et al., Advising parents of asthmatic children on passive smoking: randomized controlled trial. BMJ, Vol 318, May 29, 1999 11)Blackburn et al., Effect of strategies to reduce exposure of infants to environmental tobacco smoke in the home: cross sectional survey. BMJ, Vol 327, August 2, 2003