Young inner city children with asthma continue to be exposed to second hand smoke, despite its known association with increased chronic airway inflammation, risk for severity of asthma, (1–6)
and difficulty in managing asthma symptoms. (7,8)
Alarmingly, in our community-based, inner-city sample of high-risk young children with asthma, over half were exposed to second hand smoke and their caregiver was most commonly the household smoker. This rate of SHS exposure exceeds the 2007–2008 U.S. rate (18.2%) of children aged 3–11years living with someone who smoked inside the home (38)
and is consistent with previously reported ranges of low income children with asthma who reside with ≥ 1 smoker (47% to 69%). (12,22,39,40)
Young child age and increased number of household smokers had the strongest associations with the child’s SHS exposure. Young children are particularly at risk for high SHS exposure because they may spend up to 90% of their time in the home. (41)
This is a particular concern in light of our data indicating that many children lived in a home with two or more household smokers. The predominant household smoker was the child’s caregiver who generally was the biological mother. Our rate of caregiver smoking is comparable to prior reports of low income children with asthma. (24)
For young, preschool aged children, caregiver smoking likely results in close proximity and prolonged exposure between the smoker and the child. Moreover, most caregivers reported smoking in their own bedroom, which is likely in close proximity to the child.
Importantly, younger children had significantly higher cotinine levels than older children even when a total smoking ban was reported in the home. This suggests that total home smoking bans may be less effective for younger children. One explanation for this is that the young child may need to accompany the caregiver outside the home for the caregiver to smoke, thus the child remains exposed to SHS. Alternatively, caregivers may be less likely to truly implement a total home ban due to the difficulty leaving a young child alone in the home in order to smoke elsewhere. Moreover, the child also may experience significant exposure to smoke at an outside location, such as at a childcare site or relative’s home.
Caregiver depression and stress were high in this group of families with over one third of the caregivers endorsing symptoms compatible with depression and almost two-thirds endorsing moderate to high daily stress. Interestingly, daily asthma stress was somewhat less prevalent, suggesting that the management of a child’s asthma may have been less stressful than the daily stress of food and housing insecurity, neighborhood violence and ongoing family illnesses. We observed an association between caregiver report of depressive symptoms and higher child cotinine levels as noted in prior studies. (22)
This suggests that counseling for caregivers who smoke needs to incorporate both psychosocial screening and support.
Of note is the discordance between caregiver’s perception of the child’s well controlled asthma and moderately high symptom frequency and increased limitation of activity. Over half of caregivers rated their child’s asthma as controlled yet 52% reported limitation of activity of the child at least 4 or more days per month. This discordance may suggest caregiver tolerance of suboptimal respiratory status of the child, inappropriate expectation of child exercise capability or poor symptom recognition by the caregiver or child and highlights the need for caregiver education of accurate symptom recognition.
Pediatric providers can play an important role in reducing child SHS exposure by providing counseling for smoking cessation. (42)
Nationally 70% of smokers report a desire to quit each year, yet only 34% attempt and only 10% succeed in quitting and remain tobacco-free for a year. (35)
Unfortunately, quit rates are lowest in less educated adults (43)
represented by one out of four caregivers in our study population. Opportunities for primary care providers to address caregiver smoking cessation are numerous if families adhere to the schedule of well child and asthma care visits.(42)
For caregivers who are not ready to quit, providers can promote implementation of home smoking bans to protect their child from SHS exposures. However, it is important to note that we found that cotinine concentrations were elevated even among children whose caregivers reported a total home smoking ban, particularly for those less than 6 years of age. It may be that more specific counseling for parents of young children is need to help them implement a truly effective home smoking ban, in that our data may reflect parental inability to enforce a total home smoking ban. Further, periodic child cotinine testing may provide valuable feedback to families about the effectiveness of their efforts.
Our data also support the need for stronger policies for restricting SHS exposure in locations outside the home where children spend a large proportion of time. A child may be exposed to smoke in various locations, including the homes of extended family, neighbors and child care settings. (44,45)
Recent data also suggest that children living in apartments might be exposed to SHS from smokers in nearby apartment units. (46)
Promoting a larger ecological change in culture that includes community-wide adjustment in restricting smoking in private residences may help to reduce SHS exposure for children. (44,47)
Our study has limitations to be noted. First, we were unable to account for all SHS exposures outside of the home and household smoking behavior was based only on caregiver report. Salivary cotinine concentrations reflect SHS exposure at one point in time and may not reflect long term exposure. However, caregiver report of SHS exposure among children with asthma remains relatively stable over time. (12)
We purposely enrolled high risk children with significant asthma morbidity into our study, and this may have limited our ability to detect differences in asthma morbidity by levels of smoke exposure. Lastly, our findings can only be generalized to similar populations.