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ARTICLE

Family Composition and Children’s Exposure to

Adult Smokers in Their Homes

Katherine King, MSc, MPhila, Melissa Martynenko, MPHa, Melissa H. Bergman, MDa, Ying-Hua Liu, MD, MPAa,b,c, Jonathan P. Winickoff, MD, MPHc,d, Michael Weitzman, MDa,b,c

aDepartment of Pediatrics andbInstitute for Community Health and Research, New York University, New York, New York;cJulius B. Richmond Center of Excellence,

American Academy of Pediatrics, Elk Grove Village, Illinois;dMGH Center for Child and Adolescent Health Policy, Boston, Massachusetts

The authors have indicated they have no financial relationships relevant to this article to disclose.

What’s Known on This Subject

Exposure to secondhand smoke has many adverse effects on children’s health, and the home is the most significant site of their exposure. Individual smoking behavior is also strongly influenced by the smoking behaviors of others in the social environment.

What This Study Adds

We do not know how family context is associated with children’s likelihood of living with adult smokers, the identity of the adult smokers in households with children, or how adult smoking behavior is influenced by the family composition.

ABSTRACT

OBJECTIVE.Smoking behavior is strongly influenced by the social environment. More

information is needed about how the composition of households with children is associated with adult smoking behavior so that more effective interventions to reduce children’s secondhand smoke exposure can be devised and implemented.

METHODS.Using data from the Medical Expenditure Panel Survey 2000 –2004, we

conducted cross-sectional analyses to assess how adult smoking behavior is associ-ated with household characteristics, including the number of adults and smokers present, the relationship of the child to the head of household, and relationships between adult members of the household.

RESULTS.More than one third (34.4%) of children lived withⱖ1 adult smoker. Almost

half (49.4%) of poor children lived with a smoker, and they were more likely to live with multiple smokers compared with those who lived at ⬎400% of the federal poverty level (21.2% vs 7.8%). Approximately 5 million children lived in households headed by an adult other than their parent, and they were significantly more likely to live with smokers: 53.4% of children who lived in their grandparents’ homes and 46.2% of children in homes of other adults lived with at least 1 adult smoker, compared with 33.3% who lived in their parents’ home. A total of 59.4% of all children who lived with a smoker had a smoking mother, and 56.7% of those children lived withⱖ2 smokers, whereas only 17.0% of children whose mother did not smoke had smoking adults in the home.

CONCLUSIONS.These findings demonstrate the significant influence of household

com-position on children’s likelihood to live in homes with adult smokers.Pediatrics2009; 123:e559–e564

S

MOKING IS THEleading preventable cause of death in the United States. Secondhand smoke (SHS) exposure has numerous adverse effects on child health, including higher rates of low birth weight, sudden infant death syndrome, respiratory infections, recurrent otitis media, and increasing asthma severity.1–8A growing epidemiologic literature demonstrates that children’s SHS exposure is associated with many other problems, including attention-deficit/hyperactivity disorder,9behavior problems,10dental caries,11food insecurity,12and the metabolic syndrome.13 Children’s households are the most significant site of their SHS exposure, and⬎30% of US children live in a household with at least 1 smoker.14–20 There is no safe level of exposure to SHS.4 Although there has been a substantial increase in the use of household rules to restrict children’s exposure to tobacco smoke, even when these rules are consistently enforced, children who live with smokers have significantly increased levels of toxic expo-sure.4,21,22

With growing concern about the serious adverse consequences of children’s SHS exposure, there has been increasing discussion, research, and policy development aimed at reducing children’s exposure at home and elsewhere and helping parents quit smoking23–31; however, the dynamics of smoking in social networks suggests that smoking cessation in 1 person is relevant to other household members; as a result, to maximize tobacco control for children, interventions will have to be sensitive to the complexities of the family environment in households with

www.pediatrics.org/cgi/doi/10.1542/ peds.2008-2317

doi:10.1542/peds.2008-2317

The contents of this article are solely the responsibility of the authors and do not necessarily represent the official views of the Flight Attendant Medical Research Institute or the National Center on Minority Health and Health Disparities.

Key Words

environmental tobacco smoke, family context, disparities, smoking

Abbreviations

SHS—secondhand smoke

MEPS—Medical Expenditure Panel Survey FPL—federal poverty level

aOR—adjusted odds ratio CI— confidence interval

Accepted for publication Dec 23, 2008 Address correspondence to Michael Weitzman, MD, NYU School of Medicine, Department of Pediatrics, 550 First Ave, NBV 8S4-11, New York, NY 10016. E-mail: michael. weitzman@nyumc.org

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children.32 Using nationally representative data, this study investigated child and household characteristics that are associated with children who live withⱖ1 adult smokers and assessed which adults in children’s homes are most likely to smoke.

METHODS

Data Source

Data from the Medical Expenditure Panel Survey (MEPS), a nationally representative survey of the civil-ian, noninstitutionalized US population, sponsored by the Agency for Healthcare Research and Quality and the National Center for Health Statistics, were used. Data from 2000 –2004 were concatenated, resulting in a final sample of 46 982 children who were aged 0 to 18 years and living in 23 338 households with 52 337 adults.

Variables

A household consists of all adults and children who live in a housing unit regardless of their relationship to one another. All adults who lived in the particular household were included when assessing household characteristics. Smoking status for each adult household member was ascertained from the self-administered question-naire section of the MEPS, which is given to each mem-ber of participating households ⱖ18 years, and asks of the respondent, “Do you currently smoke?” For adults for whom data on smoking status were not reported (14% 2000 –2004), smoking status was imputed by us-ing a 2-stage procedure.

The first stage of the imputation used the 2-year structure of MEPS, assigning the smoking status re-ported in 1 year to the smoking status in the year not reported. The strategy was validated by using the 2003 and 2004 MEPS. For adults who participated in the survey in both 2003 and 2004 and who reported their smoking status in each year, 93.5% did not change their smoking status between years. Among the 6.5% who did change, there was near balance between those who quit smoking (3.4%) and those who began (3.0%). The second stage of the procedure imputed values for adults who did not report their smoking in either year of par-ticipation by applying an algorithm that used variables that are associated with smoking status developed by the Agency for Healthcare Research and Quality.16A total of 32.3% of the missing values were imputed during the first stage of the model, 67.7% in the second.

For each household, MEPS identifies a reference per-son as the head of household. The head of household is the household member who is ⱖ16 years and owns or rents the home. If ⬎1 person meets this description, then members of the household determine who is des-ignated its head. The head of household is the primary respondent for the survey, and all relationships are iden-tified in relation to him or her.

Relationships between participating children and heads of household were divided into 3 categories. The head of the household was designated a “parent” when they were a participating child’s biological or adoptive parent or the significant other of a child’s parent,

regard-less of whether they were married to the child’s biolog-ical or adopted parent. The head of the household was designated a “grandparent” when the participating child was identified as his or her grandchild or great grand-child. Heads of household who had any other relation-ship to the child were identified as “other adult rela-tives.”

Relationships between the head of the household and other adults in the home were then divided into 4 cat-egories. “Spouse” refers to any adult in the home who is identified as the wife, husband, or partner of the head of household, regardless of martial status. Alternatively, in this context, “parent” refers to the mother or father of the head of household, and “adult child” refers to adults who are identified as the daughter or son of the head of household. All other relationships between adult mem-bers of the household and the head of household were classified as “other adult relative.”

Analyses

Potential associations between child and household characteristics with the presence of a smoking adult were assessed by using bivariate and multivariable anal-yses. Bivariate analyses investigated the association be-tween the child and household characteristics with the presence and number of smoking adults in the home.16,33,34 Multivariable analyses elucidated the rela-tionship between household characteristics and adult smoking behavior. Potential covariates that showed at least a moderate association (P⬍.10) with the presence of smoking adults in the home were included in the model. A second series of analyses assessed the relation-ship between household characteristics and adult smok-ing behavior by ussmok-ing bivariate analyses. All analyses were conducted and weighted by using SUDAAN soft-ware to adjust for the complex sampling design (Re-search Triangle Institute, Cary, NC).

RESULTS

Child, Family, and Household Characteristics and Children’s Risk for Living With>Adult Smoker

A total of 34.4% of US children lived in homes with at least 1 adult smoker, and, as shown in Table 1, the likelihood that a child lived withⱖ1 adult smoker varied significantly depending on the characteristics of the child and the family in which he or she lived. Children in lower income households were substantially more likely to live with a smoking adult and with multiple smokers. Children who lived in homes below the federal poverty level (FPL) were more than twice as likely to live with

ⱖ1 adult smoker and nearly 3 times as likely to live with

ⱖ2 adult smokers than were children in households with incomes⬎400% FPL (49.4% vs 21.3% and 21.1% vs 7.8%;P⬍.0001). Black and white children both were more likely to live with ⱖ1 adult smoker than were Hispanic and Asian/Pacific Islander children (P⬍.001). Nevertheless, almost 30% of Hispanic and 25% of Asian-Pacific children lived in homes with smokers.

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significantly more likely to live with a smoking adult and to live with multiple smoking adults than were children who lived in homes headed by 1 of their parents (“pa-rental homes”; Table 1). More than half (53.4%) of children who lived in their grandparents’ homes lived with ⱖ1 adult smoker, as did 46.2% of children who lived in the homes of other adult relatives, compared with 33.3% of children in parental homes (P⬍.0001). Children who lived in nonparental homes also were more likely to live with multiple adult smokers than were children in parental homes (P⬍.0001).

As shown in Table 2, children who lived in poverty and those who belonged to a minority race/ethnicity were more likely to live in nonparentally headed house-holds (P⬍.0001). Not shown is that children who lived in nonparental homes were also significantly more likely to live withⱖ3 adults (P⬍.001), with homes headed by grandparents or other adult relatives nearly 3 times more likely to have ⱖ3 adults (59.7%, 56.6%, and 20.0%;P⬍.001).

Table 3 shows child and household characteristics

that were independently associated with the likelihood of living withⱖ1 smoker. The number of adults in the home emerged as a significant independent risk with children living with ⱖ3 adults 220% more likely to be living with a smoking adult (adjusted odds ratio [aOR]:

TABLE 1 Percentage of Children Living With Smoking Adults by Characteristics of Children and Household, MEPS 2000 – 2004 (n46 982)

Characteristic Total Smokers in Household

0 1 2 >3

Family incomea

⬍100% FPL 17.30 50.60 28.20 14.50 6.6

100%–125% FPL 5.40 55.80 26.80 13.10 4.30

125%–200% FPL 15.90 61.20 22.60 13.20 3.00

200%–400% FPL 33.10 65.90 19.80 11.60 2.70

⬎400% FPL 28.20 78.70 13.50 6.70 1.10

Race/ethnicity of childb

White (non-Hispanic) 62.10 63.70 20.10 13.00 3.30

Black (non-Hispanic) 15.60 63.90 24.00 9.10 3.00

Hispanic 18.20 72.50 18.00 6.80 2.70

Asian-Pacific Islander 4.10 77.70 15.80 5.50 1.10

Age of child

0–5 26.80 67.50 18.50 10.30 3.70

6–11 38.90 66.00 20.90 10.60 2.50

12–18 34.30 63.60 21.00 12.20 3.30

No. of children in homec

1 32.06 63.67 24.09 9.83 2.41

2 37.05 66.16 22.30 10.15 1.38

ⱖ3 30.90 63.03 23.74 10.64 2.59

Relationship of head of household to childd

Parent 93.80 66.70 19.90 10.80 2.60

Grandparent 4.90 46.60 26.60 17.30 9.50

Other adult 1.30 53.80 26.60 11.70 7.80

Total 100.00 65.60 20.30 11.10 3.00

aP.0001 for each comparison of the percentage of homes with children who (1) live withⱖ1 adult and (2) multiple adult smokers, households with children⬍100% FPL vs

⬎400% FPL.

bP.001 for each comparison of the percentage of homes with (1)adult and (2)2 adult smokers, (a) Hispanic and (b) Asian/Pacific Islander children compared with white children.

cP.001 for each comparison of the percentage of homes with (1)1 adult and (2)2 adult smokers, (a) 2 children (b)ⱖ3 children compared with 1 child.

dP.0001 for each comparison of the percentage of homes with (1)1 adult and (2)2 adult smokers, households headed (a) by grandparents and (b) by other adults compared with households with children headed by the children’s parents.

TABLE 2 Characteristics of Children and Households by Relationship of Head of Household to Child, MEPS 2000 –2004 (n46 982)

Characteristic Parental Homes

Grandparental Homes

Other Adult Relative

Homes

Total 93.80 4.90 1.30

Family incomea

⬍100% FPL 89.69 8.03 2.28

100%–125% FPL 90.10 7.89 2.00

125%–200% FPL 91.74 6.65 1.60

200%–400% FPL 94.35 4.36 1.28

⬎400% FPL 97.34 2.05 0.62

Race/ethnicity of childb

White (non-Hispanic) 96.44 2.96 0.59

Black (non-Hispanic) 86.15 10.97 2.88

Hispanic 91.31 6.28 2.41

Asian/Pacific Islander 93.64 4.05 2.32

No. of adults in home

1 95.12 3.65 1.24

2 97.03 2.31 0.66

ⱖ3 83.76 12.92 3.32

aP.0001 for family income versus percentage of children living in parent-headed homes.

bP.0001 for % of black, Hispanic or Asian/Pacific Islander versus white households that have children and are parent-headed.

TABLE 3 AOR of Living With a Smoker by Household Characteristic, MEPS 2000 –2004 (n46 982)

Characteristic aOR 95% CI P

Family income

⬍100% FPL 4.93 4.28–5.67 .000

100%–125% FPL 3.88 3.21–4.68 .001

125%–200% FPL 2.82 2.47–3.21 .000

200%–400% FPL 2.02 1.82–2.24 .000

⬎400% FPL 1.00

Race/ethnicity

White 1.00

Black 0.62a 0.55–0.70 .000

Hispanic 0.41a 0.36–0.46 .000

Asian/Pacific Islander 0.47a 0.37–0.60 .000

Census region

Northeast 1.00

Midwest 1.04 0.89–1.21 .590

South 0.99 0.87–1.14 .862

West 0.66a 0.57–0.77 .000

Adults in household

1 0.85a 0.75–0.96 .014

2 1.00

ⱖ3 2.21a 2.00–2.43 .000

Head of household’s relationship to child

Parent 0.75 0.56–1.00 .052

Grandparent 1.22 0.89–1.66 .213

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2.21 [95% confidence interval (CI): 2.00 –2.43]). In con-trast, children who lived with only 1 adult were less likely to live with a smoking adult (aOR: 0.85 [95% CI: 0.75– 0.96]). Although black children lived in homes with adult smokers in the same proportion as white children, after controlling for family income and the number of adults in the home, black children were less likely to live with a smoker (aOR: 0.62 [95% CI: 0.63– 0.80]), which also was true for Hispanic and Asian/ Pacific Islander children. Lower household income was associated with an increased risk for a child to live with an adult smoker at all income categories⬍400% FPL.

Identity of Adult Smokers in Households With Children

Adults in the United States are more likely to smoke when they live with children than when they do not (23.4% and 21.4%; P ⬍ .001; data not shown). The majority (83.3%) of smokers who lived with children were either the head of the household or his or her spouse. An additional 11.4% of adult smokers in homes with children were the adult children of the head of household. The majority (83.2%)of these adult children did not have children of their own in the home, suggest-ing that they were largely adult siblsuggest-ings of children in the home. Parents of the head of household and other adult relatives were a small proportion of smokers in house-holds with children (1.1% and 1.2%, respectively).

In households withⱖ3 adults, the heads of household or their spouse again constitutes the majority (71.3%) of smokers; however, there were significantly more (24.1%) adult children of the head of household who smoked in these homes, and there were more adult children who smoked in these homes than there were spouses who smoked.

Parental Smoking

A total of 20.0% of children lived with a smoking mother, and 17.9% lived with a smoking father (data not shown). A total of 59.4% of children who lived with smokers lived with a smoking mother. In smoking households, the child’s mother was the only smoker in 23.3% of households, and the father was the only smoker in 25.2% of households. In 16.0% of smoking households, neither the mother nor the father smoked. Both maternal and paternal smoking was highly as-sociated with the smoking behavior of other adults in the home (Table 4). A total of 56.7% of children who lived with a smoking mother and 51.6% who lived with

a smoking father lived with additional smokers. Simi-larly, 44.7% of children who lived with a smoking mother also lived with a smoking father (data not shown). In contrast, 83.0% of children who lived with a nonsmoking mother and 90.6% who lived with a non-smoking father lived with no non-smoking adults.

DISCUSSION

These nationally representative data provide a compre-hensive view of which children in the United States are likely to live with adult smokers and who the adult smokers are in these households. A total of 34.4% of children lived with a smoking adult. This rate is consis-tent with rates found in other studies and is nearly 5 times higher than the rate of nonsmoking adults who lived with smokers (7%).4,14–20The dominant risk factors for a child to live with a smoker is household poverty and increasing numbers of adults in the home. In fact, nearly 50% of children below the FPL lived with ⱖ1 adult smoker, and children in homes with ⱖ3 adults were more than twice as likely than children in homes with 2 adults to live with an adult smoker.

These data also draw attention to the complexity of our nation’s children’s living circumstances and begin to eluci-date the strong associations between these complexities and children’s exposure to SHS. Children not only live in homes with many nonparental adults, a good number of whom smoke, but also they often live in homes where their parents are not the head of the household, potentially limiting their parents’ authority about household rules in ways that are not yet clear. Moreover, nearly twice as many children in America live withⱖ3 adults than with a single adult. Previous research suggested an association between 3-adult homes and children’s exposure to SHS in bivariate analyses.16 To the best of our knowledge, how-ever, this study is the first to establish that the presence of

ⱖ3 adults in the home is an independent risk and to elucidate the specific characteristics of these homes. In particular, ⱖ3 adult homes not only are more likely to contain a smoke but also are more likely to contain mul-tiple smokers, be headed by a nonparental adult, contain nonwhite children, and be relatively poor.

The complexity of children’s homes argues that ask-ing about a mother’s smokask-ing status at a child’s medical visit is insufficient to assess the child’s risk for household SHS exposure and to offer effective counseling. The ma-jority of mothers who smoked lived with other smokers, and a substantial proportion lived withⱖ2 other smok-ers. In contrast, 17.0% of children who lived with a nonsmoking mother still had a smoking adult in the home. Moreover, as found in previous studies, even in homes with no smoking resident, there was considerable smoking by visitors, and in 25% of these homes, the visitors smoked every day.14

The Surgeon General’s report concluded that that there was no safe level of exposure to SHS.4The presence of any adult smokers in the home exposes all family members to increased morbidity and mortality,35risk for house fire,36 and the chance that the child will become a smoker,37 while decreasing the financial resources of the house-hold.38An important strategy to reduce children’s

house-TABLE 4 Proportion of Children Living With>1 Adult Smoker by

Parental Smoking Status, MEPS 2000 –2004 (n46 982) Smoking

Status

No. of Smoking Adults in Home

0 1 2 >3

Mother

Smoker 0.0 43.3 45.4 11.3

Nonsmoker 83.0 14.1 2.2 0.7

Father

Smoker 0.0 48.4 42.4 9.2

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hold SHS exposure is the counseling of parents during children’s visits to health care providers. Brief clinician counseling interventions for parental smoking cessation and SHS reduction has some influence on parental smok-ing behavior and reducsmok-ing children’s household SHS expo-sure as meaexpo-sured by household nicotine, increasing paren-tal reports of smoke-free homes, and parenparen-tal quit attempts.23,24The importance of this preventive interven-tion has been recognized by the American Academy of Pediatrics,25 American Academy of Family Physicians,26 American Medical Association,31 Public Health Service Guidelines,23,24 Maternal and Child Health Bureau Bright Futures Guidelines,27and Healthy People 2010.28

These guidelines all emphasize counseling parents, but only the American Academy of Pediatrics guidelines recognize the need to assess the smoking behavior of other adults in the home. Our findings support this emphasis on parental smoking and reinforce the impor-tance of acting on these existing guidelines to ensure that parents have every support available to change their smoking behavior.

These data also indicate that there is need for signif-icantly more research into smoking behavior at the fam-ily level. The vast majority of research into the influence of family context on adult smoking behavior has looked at concordance in the smoking behavior of part-ners.32,39,40Notably, however, previous research has not investigated the influence of other, nonpartner smoking adults on smoking cessation and SHS reduction efforts. Our findings suggest that there is a need to address these questions and explore how the presence of other adults as well as distinct family roles influence the success of smoking cessation attempts and efforts to reduce chil-dren’s household SHS exposure. In addition, it points to the need to develop strategies that can help parents in these complex family environments reduce their chil-dren’s exposure in these complex families.

MEPS data provide a longitudinal perspective on a nationally representative sample of households. This structure facilitates the imputation model used to ad-dress the nonresponse rates for adult smoking status questions. Although its large size allows for national estimates for many populations, some populations of interest are not present in sufficient number to facilitate independent analysis; for example, we were unable to perform independent analyses of foster children or American Indian/Alaska Native children.

Because interviews are conducted in the participant’s households over 2 years, the interviewer also has the op-portunity to develop a rapport with participants, increasing their willingness to share sensitive information. However, MEPS does not collect data that would allow us to quantify further children’s exposure to SHS, such as how often smoking occurs in the home. Moreover, it does not collect data on teenage smoking; as a result, our estimates do not include the contribution of this population to the exposure of other children to household SHS.

A number of previous studies examined at the asso-ciation between household smoking behavior and household characteristics. Schuster et al14 found that homes with at least 2 adults had less regular smoking in

the home than single-adult households and that father-only homes had less regular smoking than mother-father-only homes. Other studies that specifically examined smoking bans found that homes with children, nonsmoking adults, male smokers, younger smokers, or Hispanic and Asian households all were more likely to report smoke-free home rules.41–45 Although smoking bans have be-come increasingly prominent in children’s homes, they are less consistently enforced when there areⱖ2 adults or children present in the home, and even when consis-tently enforced, children still have increased levels of toxic exposure, so this approach offers incomplete pro-tection for children in these homes.4,21,22,46

CONCLUSIONS

In the past 20 years, public smoking bans have led to the protection of large numbers of adults from SHS expo-sure. Children, however, are exposed primarily in the home and so remain exposed to SHS at consistently high levels. The large number of children who live with smokers, along with the complexity of the homes in which these children live, reinforces the urgent need for strategies to help protect children from the harms of exposure to adult tobacco use.

ACKNOWLEDGMENTS

This work was made possible by a grant from the Flight Attendant Medical Research Institute and by National Institutes of Health grant P60MD000538 from the Na-tional Center on Minority Health and Health Disparities.

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DOI: 10.1542/peds.2008-2317

2009;123;e559

Pediatrics

P. Winickoff and Michael Weitzman

Katherine King, Melissa Martynenko, Melissa H. Bergman, Ying-Hua Liu, Jonathan

Family Composition and Children's Exposure to Adult Smokers in Their Homes

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http://pediatrics.aappublications.org/content/123/4/e559 including high resolution figures, can be found at:

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http://pediatrics.aappublications.org/content/123/4/e559#BIBL This article cites 32 articles, 12 of which you can access for free at:

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http://www.aappublications.org/cgi/collection/smoking_sub Smoking

http://www.aappublications.org/cgi/collection/substance_abuse_sub Substance Use

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(8)

DOI: 10.1542/peds.2008-2317

2009;123;e559

Pediatrics

P. Winickoff and Michael Weitzman

Katherine King, Melissa Martynenko, Melissa H. Bergman, Ying-Hua Liu, Jonathan

Family Composition and Children's Exposure to Adult Smokers in Their Homes

http://pediatrics.aappublications.org/content/123/4/e559

located on the World Wide Web at:

The online version of this article, along with updated information and services, is

by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

Figure

TABLE 3AOR of Living With a Smoker by HouseholdCharacteristic, MEPS 2000–2004 (n � 46 982)
TABLE 4Proportion of Children Living With >1 Adult Smoker byParentalSmokingStatus,MEPS2000–2004(n�46 982)

References

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