Adolescent Tobacco Smoke Exposure, Respiratory Symptoms, and Emergency Department Use

(1)

Adolescent Tobacco Smoke

Exposure, Respiratory Symptoms,

and Emergency Department Use

Ashley L. Merianos, PhD, CHES, a_{Roman A. Jandarov, PhD,}b_{E. Melinda Mahabee-Gittens, MD, MS}c

OBJECTIVES: Our objective was to examine the relationship between distinct tobacco smoke exposure (TSE) measures and TSE-related symptoms and emergency department (ED) and/or urgent care (UC) use among nonsmoking adolescents without asthma diagnoses. METHODS: We performed a secondary analysis of 7389 adolescents who completed the Population Assessment of Tobacco and Health Study wave 2. Logistic regression and Poisson regression models were built.

RESULTS: Adolescents with TSE were at increased risk of reporting: shortness of breath, finding it hard to exercise, wheezing during or after exercise, and dry cough at night. Adolescents who lived with a smoker and had home TSE were at increased odds of reporting wheezing or whistling in the chest, and only adolescents with home TSE were at increased risk of reporting wheezing that disturbed sleep. Adolescents with TSE were less likely to report very good or excellent overall health and physical health but were more likely to report they sometimes, often, or very often missed school because of illness. Participants who lived with a smoker and had TSE ≥1 hour were more likely to have had an ED and/or UC visit. Participants with any TSE were at increased risk of having a higher number of ED and/or UC visits.

CONCLUSIONS: Different TSE measures uniquely increased the risk of TSE-related symptoms, but any TSE increased the risk of having a higher number of ED and/or UC visits. The providers at these high-volume settings should offer interventions to adolescents who are exposed to tobacco smoke and their families to decrease these symptoms and related morbidity.

abstract

NIH

c_{Division of Emergency Medicine, Cincinnati Children}_’_{s Hospital Medical Center, and}b_{Department of}

Environmental Health, College of Medicine, and a_{College of Education, Criminal Justice, and Human Services,}

School of Human Services, University of Cincinnati, Cincinnati, Ohio

Dr Merianos conceptualized and designed the study and drafted the initial manuscript; Dr Jandarov conducted the initial analyses and drafted the initial manuscript; Dr Mahabee-Gittens conceptualized and designed the study and reviewed and revised the manuscript; and all authors approved the final manuscript as submitted.

DOI: https:// doi. org/ 10. 1542/ peds. 2018- 0266 Accepted for publication Jun 20, 2018

Address correspondence to Ashley L. Merianos, PhD, CHES, School of Human Services, University of Cincinnati, PO Box 210068, Cincinnati, OH 45221. E-mail: ashley.merianos@uc.edu

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

WHAT’S KNOWN ON THIS SUBJECT: Tobacco smoke

exposure (TSE) may contribute to lower overall health and increased acute health care visits. Evidence is lacking regarding the consequences of TSE on related symptoms, other health indicators, and health care visits among nonsmoking adolescents without asthma diagnoses.

WHAT THIS STUDY ADDS: TSE increases the risk

of respiratory symptoms, including shortness of breath and dry cough at night. Adolescents with TSE were also at increased risk of having a higher number of emergency department or urgent care visits.

To cite: Merianos AL, Jandarov RA, Mahabee-Gittens EM. Adolescent Tobacco Smoke Exposure, Respiratory Symptoms, and Emergency Department Use. Pediatrics.

(2)

Despite significant progress in tobacco control, 9.6 million US adolescents are exposed to tobacco smoke.1, 2_{Eliminating tobacco}

smoke exposure (TSE) is the only way to protect nonsmokers.3, 4

Evidence reveals that adolescents who are exposed to tobacco smoke are at substantial risk for cough, wheeze, acute respiratory infections, pneumonia, ear problems, and asthma.5, 6_{Although TSE is a}

well-recognized risk factor among children with asthma, 7_{little is known}

about related symptomatology in adolescents without asthma. In addition, TSE-attributable illnesses may contribute to increased school absenteeism, with researchers indicating that when children live with a greater number of smokers, they have more missed school days.8

Additionally, an inverse relationship between physical activity and active smoking has been reported in adolescents.9_{Active and passive}

smoking have been associated with lower overall health.10_{It is}

important to assess the relationship between types of TSE and potential TSE-attributable symptoms and other health indicators to inform intervention content that is aimed at reducing TSE among adolescents without asthma diagnoses.

Emergency departments (EDs) care for >4 million pediatric patients with potential TSE-related diagnoses (ie, upper respiratory infections or ear infections) annually.11_Children

and adolescents who are exposed, as measured by parent report and serum cotinine (which is an ideal TSE biomarker), 12_{are up to 3.5}

times more likely to seek care at EDs.13, 14_{Adolescents have high ED}

use for nonurgent and semiurgent complaints, including preventive primary care, 11, 15, 16_{but little is}

known about the relationship between TSE and ED use among adolescents. Much of the literature is focused on younger children, 17

broad age ranges, 13, 14_{and children}

and adolescents with asthma7, 18, 19

and has limited self-report measures of parental smoking status and exposure to indoor tobacco smoke to define TSE.20

Our purpose was to examine the relationship between 3 distinct TSE measures and TSE-related symptoms and other health indicators among adolescents without asthma diagnoses. We hypothesized that adolescents with TSE would be more likely to report TSE-related symptoms and miss school because of illness but less likely to report very good or excellent overall health and physical health than unexposed adolescents. We assessed the association between TSE and ED and urgent care (UC) use. We posited that adolescents with TSE would be at increased risk for higher ED and/or UC use than unexposed adolescents.

METHODS

Participants and Procedures

A secondary analysis of wave 2 data (October 3, 2014–October 30, 2015) from the Population Assessment of Tobacco and Health (PATH) Study, a longitudinal cohort study in which researchers measure tobacco use behavior and related health outcomes in US adolescents and adults, 21_{was conducted. A total}

of 7389 nonsmoking adolescents were included after excluding those who reported that they had asthma diagnoses (n = 2198) and were current smokers (n = 143). PATH Study procedures are described elsewhere.21_{A university-based}

institutional review board considered the study to be not human subjects research, and exempt from review.

Measures

TSE Variables

We used 3 exposure variables that included adolescent self-report of the following: (1) lives with a smoker who may not smoke inside the home

and whether anyone who lives in the home now smokes cigarettes, cigars, cigarillos, or filtered cigars; (2) home TSE and whether smoking tobacco products that are burned are allowed inside the home by anyone who lives in the home, including visitors or workers; and (3) having

≥1 hour of TSE (how many hours they were around others who were smoking in the past 7 days, including time at home, in a car, at school, or outdoors).

TSE-Related Symptom Outcome Variables

TSE-related symptoms included adolescent self-report of the following: shortness of breath compared with peers, finding it harder to exercise compared with peers, chest sounding wheezy during or after exercise in the past 12 months, wheezing or whistling in the chest in the past 12 months, wheezing that disturbed sleep in the past 12 months, speech that is limited to only 1 to 2 words between breaths because of wheezing in the past 12 months, and dry cough at night that is not associated with a cold or chest infection in the past 12 months. Wheezing-related questions were only asked among adolescents who reported having experienced wheezing or whistling within their lifetime (n = 942). We assessed self-reported health indicators, for which responses were collapsed into 2 categories because of skewed distributions: overall health, physical health (poor, fair, or good versus very good or excellent), and frequency of missing school because of illness (never or rarely versus sometimes, often, or very often).

ED and/or UC Use Outcome Variables

(3)

and/or UC visits for a health problem in the past 12 months.

Covariates

We selected the following covariates a priori: adolescent sex (male or female), age (12–14 years or 15–17 years), race (white, African American, or other), ethnicity (non-Hispanic or Hispanic), and parent education level (less than high school, high school or equivalent, some college, bachelor’s degree, or advanced degree). Adolescent age was dichotomized in the PATH Study for public use.

Statistical Analysis

Analyses were performed by using R version 3.3.0.22_{We used sampling}

weights provided in the PATH Study to compensate for sampling design factors (eg, oversampling), nonresponse adjustment factors, differential nonresponse rates, possible sampling frame deficiencies, and variable selection probabilities. We performed χ2_{tests to examine}

the relationship between TSE measures and covariates. We report raw sample sizes and weighted percentages to provide estimates that are generalizable to the US nonsmoking adolescent population without asthma diagnoses. We built a series of logistic regression models, adjusting for the covariates, to examine the association between TSE and TSE-related symptoms, other health indicators, and ED and/ or UC use. We report adjusted odds ratios (aORs) and 95% confidence intervals (CIs). We built multiple Poisson regression models to assess the relationship between TSE and the number of ED and/or UC visits while controlling for the covariates. We present weighted least squares means, weighted SEs, and β coefficients. A sensitivity analysis was performed to assess whether removing adolescents who may not have been diagnosed and treated for asthma and/or reported asthma symptoms of wheezing or whistling in the chest during the

past 12 months (n = 312) from analysis skewed the study’s results. Trends remained similar despite the smaller sample size and lower power. Analyses were 2 sided, with P < .05 indicating significance. Incomplete cases were excluded before each analysis.

RESULTS

Of the 7389 nonsmoking adolescents included after excluding those with asthma diagnoses (n = 2198) and current smokers (n = 143), 49.7% (n = 3651) were boys and 42.4% (n = 3181) were 12 to 14 years old. A total of 77.2% (n = 5078) were non-Hispanic, 71.1% (n = 4832) were white, 15.0% (n = 1054) were African American, and 13.9% (n = 1053) were of another race. Parent education level varied, with 12.4% obtaining less than a high school diploma (n = 1033), 21.7% completing high school or equivalent (n = 1595), 30.5% obtaining some college (n = 2098), 22.4% completing a bachelor’s degree (n = 1389), and 13.0% completing an advanced degree (n = 755). A total of 24.7% (n = 1868) of adolescents lived with a smoker, 17.7% (n = 1338) had home TSE, and 35.3% (n = 2554) had ≥1 hour of TSE.

Sociodemographic Characteristics of Adolescents by TSE

Boys and girls had similar rates of living with a smoker (24.4% and 24.9%, respectively) and home TSE (17.7% and 17.7%, respectively). There was a significant difference between boys (31.9%) and girls (37.7%) for TSE ≥1 hour (P < .001; Table 1). Adolescent age differed by living with a smoker (P = .003) and TSE ≥1 hour (P < .001), with higher rates reported among 15- to 17-year-olds (26.2% and 37.3%, respectively) compared with 12- to 14-year-olds (23.1% and 33.2%, respectively). Race differed on the basis of living with a smoker (P < .001) and home TSE (P < .001), with the

highest rates reported among African American adolescents (30.2% and 24.0%, respectively), followed by white adolescents (24.5% and 17.3%, respectively) and adolescents of other races (23.2% and 14.9%, respectively). Ethnicity differed on the basis of TSE (all P < .001), with non-Hispanic adolescents reporting higher rates of living with a smoker, home TSE, and TSE ≥1 hour (25.9%, 18.5%, and 36.9%, respectively) compared with Hispanic adolescents (20.5%, 14.7%, and 29.5%,

respectively). Parent education level differed on the basis of TSE (all

P < .001; Table 1). Participants with parents who completed high school or an equivalent had the highest rates of living with a smoker (35.9%), home TSE (26.3%), and TSE ≥1 hour (44.4%).

TSE and TSE-Related Symptoms and Other Health Indicators

Adolescents who lived with a smoker, had home TSE, and had ≥1 hour of TSE were at increased risk of reporting shortness of breath, finding it harder to exercise compared with peers, wheezing during or after exercise, and dry cough at night than were unexposed participants (all P < .001; Table 2). Adolescents who lived with a smoker (P < .001) and had home TSE (P = .02) were at increased odds of reporting wheezing or whistling in the chest, and only adolescents with home TSE (P = .02) were at increased risk of reporting wheezing that disturbed sleep. Regarding other health indicators, adolescents who lived with a smoker, had home TSE, and had ≥1 hour of TSE were less likely to report very good or excellent overall health and physical health status (all P < .001; Table 2). Participants who lived with a smoker, had home TSE, and had

(4)

TSE and ED and/or UC Use

Participants who lived with a smoker and had ≥1 hour of TSE were significantly more likely to have had an ED and/or UC visit (both

P < .001; Tables 3 and 4). Participants who lived with a smoker, had home TSE, and had ≥1 hour of TSE were at increased risk of having a higher number of ED and/or UC visits compared with unexposed participants. Specifically, participants with TSE had a mean of 1.62 to 1.65 visits compared with unexposed participants, who had a mean of 1.42 to 1.48 visits (Tables 3 and 4).

DISCUSSION

We found that more than one-third (35.3%) of the nonsmoking adolescent population without asthma diagnoses nationwide were around others who smoked for

≥1 hour in the past 7 days. Homa et al2_{found similar rates (33.8%)}

of biochemically validated TSE, as measured by serum cotinine with a mean half-life of ∼16 hours, 23_thus

reflecting relatively short-term TSE. We found that one-quarter (24.7%) of adolescents lived with a smoker,

and 17.7% lived in homes in which smoking is allowed inside the home by anyone. Similarly, Merianos et al14

found that one-quarter (24.1%) of parents nationwide reported that their children (aged 0–17 years) lived with a smoker, but only 5% had home TSE. Thus, we report exceptionally high rates of self-reported home TSE in adolescents without asthma diagnoses. One potential reason for the difference is that parents may underestimate their smoking prevalence, 24, 25_{but we used}

adolescent report of home TSE. It should be noted that adolescents who live with smokers who do not smoke inside the home are still potentially exposed to tobacco smoke and its related toxicants.26_{Despite an overall}

recent decline in TSE, 2_{we highlight}

the need for continued TSE reduction initiatives, especially for adolescents, nationwide.

We report demographic differences based on TSE. Girls had higher rates of TSE ≥1 hour. No sex differences were reported based on living with a smoker or home TSE, which differed from previous research that revealed that boys had slightly higher rates of living with a smoker and home TSE.14

We found that older adolescents

had relatively higher rates of living with a smoker and TSE ≥1 hour. Non-Hispanic adolescents had high rates of all TSE types, and African American adolescents had high rates of living with a smoker and home TSE, which is comparable to previous work.2_{African American and white}

adolescents had similar rates of TSE ≥1 hour. Parent education level varied; the lower the grade level, with the exception of less than a high school diploma, the higher the TSE prevalence, which parallels existing literature.2, 27

One of our objectives was to examine the association between TSE and potentially related symptoms and other health indicators. As posited, we found that adolescents without asthma diagnoses who had any TSE were at increased odds of having TSE-related symptoms, including shortness of breath and dry cough at night. Adolescents who lived with a smoker had higher risk of reporting wheezing or whistling in the chest, and adolescents with home TSE had increased risk of wheezing or whistling in the chest and wheezing that disturbed sleep. Wheeze-related symptoms are frequently reported as TSE-attributable symptoms.5 TABLE 1 Sociodemographic Characteristics of Adolescents by TSE Measures, PATH Study Wave 2 (2014–2015)

Sociodemographic Variable Lives With Smoker (n = 1868) Home TSE (n = 1338) TSE ≥1 h (n = 2554) No, n (%)a _Yes,_n_(%)a _P _No,_n_(%)a _Yes,_n_(%)a _P _No,_n_(%)a _Yes,_n_(%)a _P

Adolescent sex .63 .94 <.001

Male 2336 (75.6) 813 (24.4) 2547 (82.3) 587 (17.7) 2081 (68.1) 995 (31.9)

Female 3130 (75.1) 1055 (24.9) 3428 (82.3) 751 (17.7) 2576 (62.3) 1559 (37.7)

Adolescent age, y .003 .36 <.001

12–14 2750 (76.9) 866 (23.1) 2955 (82.7) 651 (17.3) 2365 (66.8) 1201 (33.2)

15–17 2703 (73.9) 995 (26.2) 3004 (81.9) 683 (18.1) 2278 (62.7) 1348 (37.3)

Adolescent race <.001 <.001 .09

White 3614 (75.5) 1192 (24.5) 3953 (82.7) 841 (17.3) 3002 (63.4) 1722 (36.6)

African American 721 (69.8) 322 (30.2) 773 (76.0) 261 (24.0) 647 (64.0) 370 (36.0)

Other 756 (76.8) 283 (23.2) 858 (85.1) 183 (14.9) 660 (67.1) 367 (32.9)

Adolescent ethnicity <.001 <.001 <.001

Non-Hispanic 3660 (74.1) 1384 (25.9) 4038 (81.5) 992 (18.5) 3068 (63.1) 1886 (36.9)

Hispanic 1709 (79.6) 446 (20.5) 1835 (85.3) 315 (14.7) 1507 (70.5) 617 (29.5)

Parent education level <.001 <.001 <.001

Less than high school 758 (72.9) 265 (27.2) 811 (77.6) 213 (22.4) 650 (63.2) 346 (36.8)

High school or equivalent 1018 (64.1) 563 (35.9) 1161 (73.7) 411 (26.3) 880 (55.6) 668 (44.4)

Some college 1452 (70.6) 630 (29.4) 1660 (80.3) 417 (19.7) 1225 (59.3) 828 (40.7)

Bachelor’s degree 1157 (84.0) 222 (16.0) 1213 (88.4) 166 (11.6) 971 (72.0) 392 (28.0)

Advanced degree 659 (88.0) 92 (12.0) 685 (91.7) 65 (8.3) 550 (74.3) 194 (25.7)

(5)

TABLE 2

TSE and Related Symptoms and Other Health Indicators Among Adolescents, PATH Study Wave 2 (2014

–

2015)

TSE-Related Symptom or Health Indicator

Lives With Smoker (

n

= 1868)

Home TSE (

n

= 1338)

TSE

≥

1 h (

n = 2554) No, n (%) a Yes, n (%) a

aOR (95% CI)

b No, n (%) a Yes, n (%) a

aOR (95% CI)

b No, n (%) a Yes, n (%) a

aOR (95% CI)

b

Shor

tness of breath

No 4668 (86.3) 752 (13.7) Reference 5101 (86.2) 830 (13.8) Reference 4012 (87.1) 605 (12.9) Reference Yes 1466 (78.5) 393 (21.5) 1.69 (1.50 – 1.90)** 1016 (75.9) 311 (24.1) 1.96 (1.72 – 2.23)** 2022 (79.6) 521 (20.4) 1.75 (1.56 – 1.96)**

Harder to exercise No

4544 (84.2) 842 (15.8) Reference 4969 (84.1) 926 (15.9) Reference 3912 (85.0) 679 (15.0) Reference Yes 1488 (79.8) 363 (20.2) 1.30 (1.16 – 1.47)** 1051 (78.5) 274 (21.5) 1.46 (1.28 – 1.67)** 2025 (79.5) 508 (20.5) 1.44 (1.29 – 1.60)**

Wheezing during or after exercise No

Wheezing or whistling in chest No

308 (46.8) 342 (53.2) Reference 327 (44.4) 406 (55.6) Reference 224 (44.8) 265 (55.2) Reference Yes 111 (35.2) 201 (64.8) 1.80 (1.40 – 2.31)** 92 (39.6) 132 (60.4) 1.39 (1.05 – 1.82) * 186 (41.2) 267 (58.8) 1.19 (0.95 – 1.51)

Wheezing that disturbs sleep No

33 (9.8) 298 (90.2) Reference 34 (9.0) 357 (91.0) Reference 25 (9.7) 234 (90.3) Reference Yes 21 (11.6) 173 (88.4) 1.58 (0.92 – 2.70) 20 (15.4) 109 (84.6) 1.92 (1.09 – 3.45) * 27 (11.0) 228 (89.0) 1.59 (0.92 – 2.70)

Wheezing that limits speech No

272 (81.1) 66 (18.9) Reference 325 (81.2) 77 (18.8) Reference 211 (80.0) 51 (20.0) Reference Yes 156 (76.4) 45 (23.6) 1.28 (0.87 – 1.90) 99 (74.3) 33 (25.7) 1.25 (0.82 – 1.92) 206 (77.9) 60 (22.1) 1.04 (0.71 – 1.53)

Dry cough at night No

Overall health status No

Physical health status No

Missed school because of illness No

4454 (82.7) 981 (17.3) Reference 4843 (82.1) 1103 (17.9) Reference 3824 (83.3) 804 (16.7) Reference Yes 1389 (74.4) 475 (25.6) 1.51 (1.35 – 1.69)** 984 (73.9) 348 (26.1) 1.53 (1.35 – 1.73)** 1925 (75.8) 624 (24.2) 1.47 (1.33 – 1.63)** an

refers to raw scores and percentages that are weighted.

b Logistic regression controlling for adolescent sex, age, race, ethnicity, and parent education le

vel.

*P

< .05; **

P

(6)

One potential explanation for the variations in symptoms by TSE measures is that those who live with a smoker and have home TSE are regularly exposed compared with those who may have temporary TSE for ≥1 hour in the past 7 days. For example, adolescents who live with someone who smokes tobacco inside the home may experience exposure at night, thus leading to wheezing that disturbed sleep. Future researchers should capture the frequency and amount of TSE and use biochemically validated measures to provide better insight into the differences found in this study.

TSE negatively impacts adolescents’

overall health and physical health.1, 10

We found that TSE translated into a lower likelihood of having very good or excellent overall health and physical health status, as hypothesized. We found that regardless of TSE measure, adolescents with TSE reported that it was harder to exercise compared with peers and wheezing during or after exercise. Previous

work reveals that TSE negatively impacts exercise capacity in adults, 28

which was reported in our study. TSE may cause overall decreased maximum oxygen uptake because TSE reduces oxygen delivery to the myocardium and potentially reduces the myocardium’s ability to use the delivered oxygen effectively.5_This

physiologic response caused by TSE inhibits exercise. Additionally, participants who lived with a smoker, had home TSE, and were around TSE for ≥1 hour were at increased risk of frequently missing school because of being sick. This expanded on previous findings that living with a smoker contributed to increased school absenteeism.8_{TSE contributes}

to increased morbidity and related consequences in adolescents without asthma diagnoses.

Another study objective was to examine the relationship between TSE and ED and/or UC use among adolescents who are often high users of these settings. The literature reveals mixed findings among youth; thus, this study was conducted to

further assess these relationships by using 3 distinct TSE measures. As hypothesized, we found that adolescents who were exposed by living with a smoker or had ≥1 hour of TSE were at an elevated risk of ED and/or UC use compared with adolescents who did not live with a smoker or had no TSE in the past 7 days. These findings align with previous work by Merianos et al, 14

which found that children who lived with a smoker were at an increased risk, and children with TSE levels (as measured by serum cotinine) that were indicative of active smoking (≥3 ng/mL) were 3.5 times more likely to select an ED as the place they most often go for health care.13

Interestingly, we found that all TSE types increased the risk of having a higher number of ED and/or UC visits. These venues should be considered high-priority settings for TSE prevention intervention because of the increased interaction with adolescents who are exposed. EDs are typically the main sources for primary care and preventable

TABLE 3 TSE and ED and/or UC Use Among Adolescents, PATH Study Wave 2 (2014–2015)

Lives With Smoker (n = 1868) Home TSE (n = 1338) TSE ≥1 h (n = 2554)

ED and/or UC Visit Logistic Regressiona

No, n (%)b _Yes,_n_(%)b _{aOR (95% CI)} _No,_n_(%)b _Yes,_n_(%)b _{aOR (95% CI)} _No,_n_(%)b _Yes,_n (%)b

aOR (95% CI)

TSE

No 4377 (80.0) 1060 (20.0) Reference 4760 (79.3) 1188 (20.7) Reference 3758 (80.7) 872 (19.3) Reference Yes 1420 (75.4) 444 (24.6) 1.29 (1.15–1.43)** _{1016 (76.3)} _{316 (23.7)} _{1.12 (0.99}_–_1.27) _{1931 (75.0)} _{618 (25.0)} _{1.33 (1.21}_–_1.47)** a_{Regression controlling for adolescent sex, age, race, ethnicity, and parent education level.}

b_n_{refers to raw scores and percentages that are weighted.} **_P_{< .001.}

TABLE 4 TSE and ED and/or UC Use Among Adolescents, PATH Study Wave 2 (2014–2015)

Lives With Smoker (n = 1868) Home TSE (n = 1338) TSE ≥1 h (n = 2554)

No. ED and/or UC visits

Poisson Regressiona _{No. ED and/or UC} visits

Poisson Regressiona

Mean (SE) aRR (95% CI) Mean (SE) aRR (95% CI) Mean (SE) aRR (95% CI)

TSE

No 1.47 (0.03) Reference 1.48 (0.03) Reference 1.42 (0.03) Reference

Yes 1.62 (0.06) 1.081 (1.00–1.17)* _{1.65 (0.07)} _{1.11 (1.01}_–_1.21)* _{1.64 (0.05)} _{1.10 (1.02}_–_1.18)* aRR, adjusted relative risk.

(7)

health care services for Americans who have limited access to primary health care settings.29_Previous

TSE reduction initiatives reveal that health care providers and parents who smoke and bring their children to ED and/or UC settings are highly receptive to these feasible efforts.30, 31_{In addition, delivering}

interventions in these settings may increase caregiver quit attempts and successful quits and ultimately decrease child TSE.32–34_{This includes}

the implementation of electronic health record–embedded clinical decision support systems that can be easily incorporated into busy ED and/or UC providers’ workloads.34, 35

However, despite these practical options, prevention initiatives in these settings, including the first step of TSE screening, are infrequent.36–38

Efforts supported by evidence-based policies and procedures, including the implementation of systems to prevent, identify, and treat tobacco dependence, may help to increase ED and/or UC professionals’

engagement with adolescents and their families about eliminating TSE to protect their overall health.39, 40

Study strengths include examining the relationship between several TSE measures and ED and/or UC use by using a sample that is generalizable to the US nonsmoking adolescent population without asthma diagnoses and controlling for sociodemographics that may influence this relationship. Despite the study strengths, the limitations should be noted. We were limited to public-use variables provided in the PATH Study, including relying on adolescent report of TSE, which may have been underreported, 41, 42

rather than using biomarkers. We relied on parent report of ED and/or UC use because adolescent report

was unavailable. Although authors of other studies have used population-based survey data that rely on parent report of a child’s health care use, 13, 14_{future researchers should}

examine the validity of parent report by comparing responses to medical records. Residual confounding may have biased results, although we adjusted for well-known confounders. We adjusted for parent education level as a proxy for socioeconomic status because the PATH Study does not provide publicly available information on income level or health insurance. Although it is possible that some adolescents who were not diagnosed yet were included, the proportion of adolescents with asthma who were excluded (23%) was higher than in other national data, which indicate that ∼18% have had lifetime asthma.43_{Finally, inferences are}

not causal or temporal because we analyzed 1 wave of data. Because the PATH Study continues to collect data, it would be of interest to examine the longitudinal relationship between TSE and related symptoms and ED and/or UC use among nonsmoking adolescents.

CONCLUSIONS

With this study, we add to the literature by examining the potential impact TSE has on TSE-related symptoms and ED and/or UC use among solely nonsmoking adolescents without asthma diagnoses and revealing that a considerable proportion are exposed by living with a smoker, at home, and for ≥1 hour. We found that different TSE types uniquely increased the risk of TSE-related symptoms, other health indicators, and ED and/ or UC use. However, all TSE types

increased the risk of having a higher number of visits to an ED and/or UC, and this has not been previously reported. Because adolescents are high users of EDs and/or UCs for primary care reasons, these venues are high-volume settings that should be used to offer interventions to adolescents with TSE and their families. They should be educated on the importance of TSE elimination to increase their overall health and wellness, especially because they may not be receiving preventive care elsewhere. There are feasible options available for EDs and UCs to implement such efforts that would not interfere with clinical flow. Targeting initiatives to adolescents with potential TSE-related symptoms and illnesses may assist in reducing TSE and related morbidity. Sustained TSE reduction research is needed to better understand TSE-related symptoms and ED and/or UC use. Physicians at EDs and UCs should consider referring adolescents with asthma symptoms (eg, recurrent wheeze, shortness of breath, or difficulty exercising) for a formal evaluation to ensure that undiagnosed cases are properly treated. Longitudinal research with objective measures would provide better insight into the influence that TSE has on related symptoms, overall health, and ED and/or UC use over time.

ABBREVIATIONS

aOR: adjusted odds ratio CI: confidence interval ED: emergency department PATH: Population Assessment of

Tobacco and Health TSE: tobacco smoke exposure UC: urgent care

FUNDING: Funded by the National Institute on Drug Abuse (grant 1K01DA044313) and the Eunice Kennedy Shriver National Institute of Child Health and Human Development (grant 1R01HD083354). Funded by the National Institutes of Health (NIH).

(8)

REFERENCES

1. US Department of Health and Human Services. The Health Consequences of Smoking–50 Years of Progress. A Report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2014 2. Homa DM, Neff LJ, King BA, et al;

Centers for Disease Control and Prevention. Vital signs: disparities in nonsmokers’ exposure to secondhand smoke–United States, 1999-2012. MMWR Morb Mortal Wkly Rep. 2015;64(4):103–108

3. Committee on Environmental Health; Committee on Substance Abuse; Committee on Adolescence; Committee on Native American Child. From the American Academy of Pediatrics: policy statement–tobacco use: a pediatric disease [published correction appears in Pediatrics. 2010;125(4):861]. Pediatrics. 2009;124(5):1474–1487 4. Farber HJ, Nelson KE, Groner JA,

Walley SC; Section on Tobacco Control. Public policy to protect children from tobacco, nicotine, and tobacco smoke. Pediatrics. 2015;136(5):998–1007 5. US Department of Health and Human

Services. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2006 6. US Department of Health and Human

Services. A Report of the Surgeon General: How Tobacco Smoke Causes Disease: What it Means to You. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2010

7. Wang Z, May SM, Charoenlap S, et al. Effects of secondhand smoke exposure on asthma morbidity and health care utilization in children: a systematic review and meta-analysis. Ann Allergy

Asthma Immunol. 2015;115(5): 396–401.e2

8. Levy DE, Winickoff JP, Rigotti NA. School absenteeism among children living with smokers. Pediatrics. 2011;128(4):650–656

9. Charilaou M, Karekla M, Constantinou M, Price S. Relationship between physical activity and type of smoking behavior among adolescents and young adults in Cyprus. Nicotine Tob Res. 2009;11(8):969–976

10. Heshmat R, Qorbani M, Safiri S, et al. Association of passive and active smoking with self-rated health and life satisfaction in Iranian children and adolescents: the CASPIAN IV study. BMJ Open. 2017;7(2):e012694

11. US Department of Health and Human Services; Centers for Disease Control and Prevention; National Center for Health Statistics. National hospital ambulatory medical care survey: 2015 emergency department summary tables. 2015. Available at: https:// www. cdc. gov/ nchs/ data/ nhamcs/ web_ tables/ 2015_ ed_ web_ tables. pdf. Accessed April 15, 2018

12. Benowitz NL. Cotinine as a

biomarker of environmental tobacco smoke exposure. Epidemiol Rev. 1996;18(2):188–204

13. Merianos AL, Jandarov RA, Mahabee-Gittens EM. Secondhand smoke exposure and pediatric healthcare visits and hospitalizations. Am J Prev Med. 2017;53(4):441–448

14. Merianos AL, Odar Stough C, Nabors LA, Mahabee-Gittens EM. Tobacco smoke exposure and health-care utilization among children in the United States. Am J Health Promot. 2018;32(1):123–130

15. Weiss AL, D’Angelo LJ, Rucker AC. Adolescent use of the emergency department instead of the primary care provider: who, why, and how urgent? J Adolesc Health. 2014;54(4):416–420

16. Wilson KM, Klein JD. Adolescents who use the emergency

department as their usual source of care. Arch Pediatr Adolesc Med. 2000;154(4):361–365

17. Hill SC, Liang L. Smoking in the home and children’s health. Tob Control. 2008;17(1):32–37

18. Crombie IK, Wright A, Irvine L, Clark RA, Slane PW. Does passive smoking increase the frequency of health service contacts in children with asthma? Thorax. 2001;56(1):9–12 19. Merianos AL, Jandarov RA,

Mahabee-Gittens EM. Association of secondhand smoke exposure with asthma symptoms, medication use, and healthcare utilization among asthmatic adolescents. J Asthma. 2018:1–11 20. Öberg M, Jaakkola MS, Woodward A,

Peruga A, Prüss-Ustün A. Worldwide burden of disease from exposure to second-hand smoke: a retrospective analysis of data from 192 countries. Lancet. 2011;377(9760):139–146 21. US Department of Health and Human

Services. Population Assessment of Tobacco and Health (PATH) Study [United States] Public Use-Files: User Guide. Ann Arbor, MI: Inter-university Consortium for Political and Social Research; 2017

22. R Core Team. R: A language and environment for statistical computing. 2013. Available at: www. R- project. org/ . Accessed January 20, 2018

23. Benowitz NL, Hukkanen J, Jacob P III. Nicotine chemistry, metabolism, kinetics and biomarkers. Handb Exp Pharmacol. 2009;(192):29–60 24. Connor Gorber S, Schofield-Hurwitz S,

Hardt J, Levasseur G, Tremblay M. The accuracy of self-reported smoking: a systematic review of the relationship between self-reported and cotinine-assessed smoking status. Nicotine Tob Res. 2009;11(1):12–24

25. Mahabee-Gittens EM, Gordon JS. Missed opportunities to intervene with caregivers of young children highly exposed to secondhand tobacco smoke [published correction appears in Prev Med. 2016;84:97]. Prev Med. 2014;69:304–305

(9)

27. Hiscock R, Bauld L, Amos A, Fidler JA, Munafò M. Socioeconomic status and smoking: a review. Ann N Y Acad Sci. 2012;1248(1):107–123

28. Dunbar A, Gotsis W, Frishman W. Second-hand tobacco smoke and cardiovascular disease risk: an epidemiological review. Cardiol Rev. 2013;21(2):94–100

29. Rhodes KV, Gordon JA, Lowe RA; The Society for Academic Emergency Medicine Public Health and Education Task Force Preventive Services Work Group. Preventive care in the emergency department, part I: clinical preventive services–are they relevant to emergency medicine? Acad Emerg Med. 2000;7(9):1036–1041

30. Mahabee-Gittens EM, Gordon J. Acceptability of tobacco cessation interventions in the pediatric emergency department. Pediatr Emerg Care. 2008;24(4):214–216

31. Mahabee-Gittens EM, Dexheimer JW, Tabangin M, et al. An electronic health record-based strategy to address child tobacco smoke exposure. Am J Prev Med. 2018;54(1):64–71

32. Mahabee-Gittens EM, Khoury JC, Ho M, Stone L, Gordon JS. A smoking cessation intervention for low-income smokers in the ED. Am J Emerg Med. 2015;33(8):1056–1061

33. Mahabee-Gittens EM, Gordon JS, Krugh ME, Henry B, Leonard AC. A smoking cessation intervention plus proactive quitline referral in the pediatric emergency department: a pilot study. Nicotine Tob Res. 2008;10(12):1745–1751 34. Mahabee-Gittens EM, Merianos AL,

Dexheimer JW, et al. Utilization of a clinical decision support tool to reduce child tobacco smoke exposure in the urgent care setting. Pediatr Emerg Care. In press

35. Mahabee-Gittens EM, Dexheimer JW, Gordon JS. Development of a tobacco cessation clinical decision support system for pediatric emergency nurses. Comput Inform Nurs. 2016;34(12):613–614

36. Lustre BL, Dixon CA, Merianos AL, Gordon JS, Zhang B, Mahabee-Gittens EM. Assessment of tobacco smoke exposure in the pediatric emergency department. Prev Med. 2016;85:42–46 37. Bernstein SL, Boudreaux ED, Cydulka

RK, et al; American College of Emergency Physicians Task Force on Smoking Cessation. Tobacco control interventions in the emergency department: a joint statement of emergency medicine organizations. Ann Emerg Med. 2006;48(4):e417–e426 38. Wilson KM, Wesgate SC, Best D,

Blumkin AK, Klein JD. Admission

screening for secondhand tobacco smoke exposure. Hosp Pediatr. 2012;2(1):26–33

39. Farber HJ, Walley SC, Groner JA, Nelson KE; Section on Tobacco Control. Clinical practice policy to protect children from tobacco, nicotine, and tobacco smoke. Pediatrics. 2015;136(5):1008–1017 40. Jenssen BP, Wilson KM. Tobacco

control and treatment for the pediatric clinician: practice, policy, and research updates. Acad Pediatr. 2017;17(3):233–242

41. Avila-Tang E, Elf JL, Cummings KM, et al. Assessing secondhand smoke exposure with reported measures. Tob Control. 2013;22(3):156–163

42. Prochaska JJ, Grossman W, Young-Wolff KC, Benowitz NL. Validity of self-reported adult secondhand smoke exposure. Tob Control. 2015;24(1):48–53

(10)

DOI: 10.1542/peds.2018-0266 originally published online August 6, 2018;

2018;142;

Pediatrics

Ashley L. Merianos, Roman A. Jandarov and E. Melinda Mahabee-Gittens

Department Use

Adolescent Tobacco Smoke Exposure, Respiratory Symptoms, and Emergency

Services

Updated Information &

http://pediatrics.aappublications.org/content/142/3/e20180266

including high resolution figures, can be found at:

References

http://pediatrics.aappublications.org/content/142/3/e20180266#BIBL

This article cites 35 articles, 11 of which you can access for free at:

Subspecialty Collections

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

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

icine_sub

http://www.aappublications.org/cgi/collection/adolescent_health:med Adolescent Health/Medicine

following collection(s):

This article, along with others on similar topics, appears in the

Permissions & Licensing

http://www.aappublications.org/site/misc/Permissions.xhtml

in its entirety can be found online at:

Information about reproducing this article in parts (figures, tables) or

Reprints

http://www.aappublications.org/site/misc/reprints.xhtml

(11)

Adolescent Tobacco Smoke Exposure, Respiratory Symptoms, and Emergency Department Use

Adolescent Tobacco Smoke

Exposure, Respiratory Symptoms,

and Emergency Department Use

abstract

DOI: 10.1542/peds.2018-0266 originally published online August 6, 2018;

2018;142;

Pediatrics

Ashley L. Merianos, Roman A. Jandarov and E. Melinda Mahabee-Gittens

Department Use

Adolescent Tobacco Smoke Exposure, Respiratory Symptoms, and Emergency

DOI: 10.1542/peds.2018-0266 originally published online August 6, 2018;

2018;142;

Pediatrics

Ashley L. Merianos, Roman A. Jandarov and E. Melinda Mahabee-Gittens

Department Use

Adolescent Tobacco Smoke Exposure, Respiratory Symptoms, and Emergency

http://pediatrics.aappublications.org/content/142/3/e20180266

located on the World Wide Web at:

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