Susan B. Meltzer

Reduction of environmental tobacco smoke exposure in asthmatic children. A 2-year follow-up.

STUDY OBJECTIVE To examine the long-term maintenance of a previously reported behavioral counseling intervention to reduce asthmatic childrens exposure to environmental tobacco smoke (ETS). PARTICIPANTS Families of asthmatic children (6 to 17 years), including at least one parent who smoked in the home, recruited from four pediatric allergy clinics. DESIGN Participants were randomized to one of three groups: behavioral counseling to reduce ETS exposure, self-monitoring control, and usual medical care control. Counseling concluded at month 6, and the original trial ended at month 12. Two follow-up interviews occurred at months 20 and 30. MEASUREMENTS AND RESULTS The originally reported analysis of baseline to 12 months was reanalyzed with a more robust restricted maximum likelihood procedure. The 2-year follow-up period was analyzed similarly. Significantly greater change occurred in the counseling group than the control groups and was sustained throughout the 2 years of follow-up. Further exploratory analyses suggested that printed counseling materials given to all participants at month 12 (conclusion of the original study) were associated with decreased exposure in the control groups. CONCLUSION Such long-term maintenance of behavior change is highly unusual in the general behavioral science literature, let alone for addictive behaviors. We conclude that ETS exposure can be reduced and that a clinician-delivered treatment may provide substantial benefit.

Clinical Investigations: AsthmaReduction of Environmental Tobacco Smoke Exposure in Asthmatic Children: A 2-Year Follow-up

STUDY OBJECTIVE To examine the long-term maintenance of a previously reported behavioral counseling intervention to reduce asthmatic childrens exposure to environmental tobacco smoke (ETS). PARTICIPANTS Families of asthmatic children (6 to 17 years), including at least one parent who smoked in the home, recruited from four pediatric allergy clinics. DESIGN Participants were randomized to one of three groups: behavioral counseling to reduce ETS exposure, self-monitoring control, and usual medical care control. Counseling concluded at month 6, and the original trial ended at month 12. Two follow-up interviews occurred at months 20 and 30. MEASUREMENTS AND RESULTS The originally reported analysis of baseline to 12 months was reanalyzed with a more robust restricted maximum likelihood procedure. The 2-year follow-up period was analyzed similarly. Significantly greater change occurred in the counseling group than the control groups and was sustained throughout the 2 years of follow-up. Further exploratory analyses suggested that printed counseling materials given to all participants at month 12 (conclusion of the original study) were associated with decreased exposure in the control groups. CONCLUSION Such long-term maintenance of behavior change is highly unusual in the general behavioral science literature, let alone for addictive behaviors. We conclude that ETS exposure can be reduced and that a clinician-delivered treatment may provide substantial benefit.

The Variability of Urinary Cotinine Levels in Young Children: Implications for Measuring ETS Exposure

This study examined the within-subject variability of urinary cotinine levels in young children (aged = 0.6-7.2 years) of smoking parents to determine the number of urine samples needed to provide accurate estimates of exposure to environmental tobacco smoke (ETS) for different time intervals. Secondary analyses were conducted of five independent studies (N = 376), in which multiple urinary cotinine measures had been collected over time periods up to 13 months. Over measurement periods of 4-15 days, the within-subject cotinine levels varied 3-5 times more than would be expected based on measurement error alone. Over 7-13 months, the within-subject variability was 10-20 times higher than would be expected based on the measurement error. Findings indicated that cotinine measures from single urine samples provided highly accurate estimates of only recent exposure (i.e., 2-3 days; rho = 0.99). To achieve similarly precise estimates of the mean cotinine level of an individual child over 4-15 days, up to nine urine samples may be necessary. Up to 12 urine samples may be required to achieve similarly precise estimates of ETS exposure over a 4- to 13-month period. Epidemiologic and clinical research on ETS exposure in children can benefit from multiple urine samples (a) to accurately measure average exposure at the level of the individual child, (b) to describe temporal patterns, (c) to detect incidences of peak exposure that would remain underrecognized if monitoring is limited to a single time point, and (d) to establish stable baseline levels and endpoints based on urine samples collected over clinically relevant time periods.

Involuntary smoking and asthma.

Involuntary smoking is the third leading preventable cause of death, and among children it causes lower respiratory infections, middle ear disease, sudden infant death syndrome, and asthma. Half the worlds children may be exposed to environmental tobacco smoke (ETS), exacerbating symptoms in 20% of children with asthma. Recent studies have reinforced previous conclusions that ETS exposure causes onset of childhood asthma and exacerbation of symptoms throughout life. The exact mechanisms by which this is accomplished are still unclear, as are the relative contributions of prenatal versus postnatal exposure. However, favorable health outcomes can be attained with reduced exposure. Among the few studies of ETS exposure reduction interventions, low-intensity advice methods appeared ineffective, and counseling parent smokers appeared successful. Direct counseling of school-aged children to avoid ETS has yet to be tested. Community norms may need to shift further in favor of protecting children and others from ETS before minimal interventions can be successful. This will require combined and ongoing efforts of the medical and public health establishments, in concert with legislation mandating tobacco-free public places and with ETS-related media campaigns.

Increasing asthma knowledge and changing home environments for Latino families with asthmatic children

We tested an asthma education program in 204 underserved Latino families with an asthmatic child. The education program consisted of one or two sessions delivered in each familys home in the targeted participants preferred language by a bilingual, bicultural educator. We encouraged, but did not require, attendance by the child. The curriculum was culturally-tailored, and all participants received education on understanding asthma, preventing asthma attacks, and managing asthma. Outcomes included change in asthma knowledge and change in home environment asthma management procedures. Asthma knowledge increased significantly (39 to 50% correct from pre- to post-test, P < 0.001) and participants made significant changes to the childs bedroom environment (mean number of triggers decreased from 2.4 to 1.8, P < 0.001; mean number of controllers increased from 0.7 to 0.9, P < 0.001). The results support the value of asthma education and its importance in the national agenda to reduce health disparities among minorities.

Toward a simplified measure of asthma severity for applied research.

There is no universally accepted and validated measure of asthma severity. For community research, clinical tests are too costly, and epidemiological assessments provide inadequate data on severity. Symptom measures may offer a practical alternative. This study assessed psychometric properties of symptom ratings of 91 asthmatic children. Reliability and validity of scales created from these items were examined. A sum scale of symptom ratings was internally consistent, reliable across time, and associated with concurrent health indices. This scale may be a practical measure of severity for use in community-based research.

Latino Children with Asthma: Rates and Risks for Medical Care Utilization

Latino families have been reported to underutilize health care services compared with families from other ethnic backgrounds. As part of a community trial in a low income Latino population designed to decrease environmental tobacco smoke (ETS) exposure in children with asthma in San Diego, we examined unscheduled medical care for asthma. Latino families (N = 193) reported information about medical care use for their children during the past 12 months. About 23% were hospitalized, 45% used the emergency department, and 60% used urgent care services. About 8.5% of families had two or more hospitalizations in 12 months. Most families were insured by Medicaid or had no insurance. Significant risk factors for a childs hospitalization were age (under age six), failure to use a controller medication, and a parental report of the childs health status as being poor. Risk factors for emergency department use were age (under age six) and male gender. These findings indicate that low‐income Latino families with young children with asthma lack the medical resources necessary for good asthma control. Quality and monitored health care with optimization of asthma management could reduce costly acute care services.

Reduction of secondary smoke exposure in asthmatic children : parent counseling

Epidemiological evidence shows that childrens exposure to secondhand tobacco smoke increases their risk of respiratory illness. This study evaluated five families and their asthmatic children (aged 5-14 years) in an outpatient counseling program for reducing the childrens exposure to passive smoking. Intervention included biweekly counseling/instructions for parents to limit their childrens tobacco exposure. A multiple-baseline, quasiexperimental design was used for self-reported measures of the childrens smoke exposure and the parents smoking frequency. Counseling was associated with smoke exposure reduction of 40-80% from baseline for each of 5 children, with most improvements sustained during follow-up. This study provides support for the development of tobacco exposure prevention programs for children with pulmonary disease.

Association between Residential Tobacco Smoking Bans, Smoke Exposure, and Pulmonary Function: A Survey of Latino Children with Asthma

Exposure to environmental tobacco smoke (ETS) is a risk factor for asthma development and progression. ETS exposure among children takes place mainly in the home. This paper examines the relationship between household smoking restrictions, the level of ETS exposure, and the asthma status of a sample of 192 low-income Latino asthmatic children, living with at least one smoker. Families were recruited throughout San Diego County, California. Mothers were interviewed on use of smoking restriction policies, possible correlates of these policies, their childrens ETS exposure, asthma morbidity, and use of medical care. The childrens pulmonary function was also assessed. As compared with the lack of smoking restrictions, a total ban on smoking was associated with a significantly lower reported level of childrens ETS exposure at home (p < 0.05), in the car (p < 0.05), and overall (p < 0.01). Multivariate analyses indicated that having a smoking ban was associated with less severe asthma symptoms (p < 0.05), le...