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1.  Randomized Controlled Trial to Improve Care for Urban Children With Asthma 
Objective
To evaluate the impact of the School-Based Asthma Therapy trial on asthma symptoms among urban children with persistent asthma.
Design
Randomized trial, with children stratified by smoke exposure in the home and randomized to a school-based care group or a usual care control group.
Setting
Rochester, New York.
Participants
Children aged 3 to 10 years with persistent asthma.
Interventions
Directly observed administration of daily preventive asthma medications by school nurses (with dose adjustments according to National Heart, Lung, and Blood Institute Expert Panel guidelines) and a home-based environmental tobacco smoke reduction program for smoke-exposed children, using motivational interviewing.
Main Outcome Measure
Mean number of symptom-free days per 2 weeks during the peak winter season (November-February), assessed by blinded interviews.
Results
We enrolled 530 children (74% participation rate). During the peak winter season, children receiving preventive medications through school had significantly more symptom-free days compared with children in the control group (adjusted difference=0.92 days per 2 weeks; 95% confidence interval, 0.50-1.33) and also had fewer nighttime symptoms, less rescue medication use, and fewer days with limited activity (allP<.01). Children in the treatment group also were less likely than those in the control group to have an exacerbation requiring treatment with prednisone (12% vs 18%, respectively; relative risk=0.64; 95% confidence interval, 0.41-1.00). Stratified analyses showed positive intervention effects even for children with smoke exposure (n=285; mean symptom-free days per 2 weeks: 11.6 for children in the treatment group vs 10.9 for those in the control group; difference=0.96 days per 2 weeks; 95% confidence interval, 0.39-1.52).
Conclusions
The School-Based Asthma Therapy intervention significantly improved symptoms among urban children with persistent asthma. This program could serve as a model for improved asthma care in urban communities.
doi:10.1001/archpediatrics.2011.1
PMCID: PMC3600609  PMID: 21383275
2.  Collaboration Between Oregon’s Chronic Disease Programs and Medicaid to Decrease Smoking Among Medicaid-Insured Oregonians With Asthma 
Preventing Chronic Disease  2005;2(Spec No):A12.
Background
Environmental tobacco smoke is a leading environmental asthma trigger and has been linked to the development of asthma in children and adults. Smoking cessation and reduced exposure to secondhand tobacco smoke are key components of asthma management. We describe a partnership involving two state agencies and 14 health plans; the goal of the partnership was to decrease smoking and exposure to environmental tobacco smoke among Medicaid-insured Oregonians with asthma.
Context
Oregon's asthma rate is higher than that of the national population, and approximately one third of Oregonians with asthma smoke. The Health Promotion and Chronic Disease Prevention Program (HPCDP) in the Oregon Department of Human Services has collaborated with the Office of Medical Assistance Programs (OMAP) to promote preventive care at the population level.
Methods
Two HPCDP programs — the Oregon Asthma Program and the Oregon Tobacco Prevention and Education Program — worked with OMAP to launch the statewide Asthma–Tobacco Integration Project in 2003. A primary focus of the project is the development of partnerships among health plans, health care providers, and large health care organizations to integrate asthma management and smoking control through systems innovations and provider education. OMAP and its participating health plans also decided to focus cessation efforts on its members with chronic diseases. In addition, HPCDP has collaborated with OMAP to distribute educational tools and information about tobacco's impact on asthma morbidity to Oregon's health care providers who serve low-income Oregonians.
Consequences
The partnership between OMAP and HPCDP program staff members has allowed them to discuss problems, leverage resources, and obtain support for many public health initiatives. In addition, OMAP–HPCDP collaboration on educational workshops and outreach to health care providers has helped convince quality improvement specialists and administrators about the importance of addressing smoking among patients with asthma. The Asthma–Tobacco Integration Project has also led to formative research aimed at increasing community involvement in promoting tobacco-free environments.
Interpretation
Collaboration between HPCDP and OMAP has been an important factor in Oregon's successful smoking cessation efforts in general and in recent efforts to address tobacco use among Oregonians with asthma.
PMCID: PMC1459462  PMID: 16263045
3.  Internet-based monitoring of asthma symptoms, peak flow meter readings, and absence data in a school-based clinical trial 
Background
Asthma is the most common chronic childhood disease and has significant impact on morbidity and mortality in children. Proper adherence to asthma medication has been shown to reduce morbidity among those with asthma; however, adherence to medications is known to be low, especially among low-income urban populations. We conducted a randomized clinical trial to examine the effectiveness of an intervention designed to increase adherence to asthma medication among children with asthma that required daily collection of data.
Purpose and Methods
A specifically designed web-based data collection system, the Asthma Agents System, was used to collect daily data from participant children at school. These data were utilized to examine the intervention’s effectiveness in reducing the frequency of asthma exacerbations. This study examines the Asthma Agents System’s effect on the frequency of missing data. Data collection methods are discussed in detail, as well as the processes for retrieving missing data.
Results
For the 290 children randomized, 97% of the daily data expected were available. Of the outcome data retrieved via the Asthma Agents System, 5% of those expected were missing during the period examined.
Limitations
Challenges encountered in this study include issues regarding the use of technology in urban school settings, transfer of data between study sites, and availability of data during school breaks.
Conclusions
Use of the Asthma Agents System resulted in lower rates of missing data than rates reported elsewhere in the literature.
doi:10.1177/1740774507086647
PMCID: PMC2763552  PMID: 18283077
4.  Design of the Supervised Asthma Therapy Study: Implementing an adherence intervention in urban elementary schools 
Contemporary clinical trials  2007;29(2):304-310.
Background
Inhaled corticosteroids, when properly used, can offer considerable protection against asthma-related morbidity. However, adherence to prescribed inhaled steroids among children is low and rates differ markedly by population. The lowest rates of adherence and highest rates of morbidity are among inner-city and low income populations.
Purpose
To describe the design of a school-based clinical trial in a largely minority population that is examining the efficacy of a school-based intervention intended to increase adherence to daily inhaled corticosteroids.
Methods
The supervised asthma therapy study is a two-group randomized longitudinal trial. Children were randomly assigned to either school-based supervised asthma therapy or parent supervised asthma therapy. Children were followed longitudinally for 15 months. The primary outcome of the study is the time-averaged difference between the two groups in the percentage of children experiencing at least one asthma exacerbation each month.
Results
A web-based data collection system was designed to capture data at school. A total of 295 students, recruited from community and school sites, who attended one of 36 urban elementary schools enrolled in the study and 290 were randomized. The average age of the students was 10.0 years (sd=2.1), 91% were African American, 8% were white, and 1% were of other racial groups. 57% of students were male. The study has been recently completed and results are being analyzed.
Conclusions
Intervention studies requiring daily medication supervision and daily data collection can be successfully conducted within the elementary school environment.
doi:10.1016/j.cct.2007.07.010
PMCID: PMC2271116  PMID: 17804302
asthma; children; clinical trial; adherence
5.  Environmental risk factors of childhood asthma in urban centers. 
Environmental Health Perspectives  1995;103(Suppl 6):59-62.
Asthma morbidity and mortality are disproportionately high in urban centers, and minority children are especially vulnerable. Factors that contribute to this dilemma include inadequate preventive medical care for asthma management, inadequate asthma knowledge and management skills among children and their families, psychosocial factors, and environmental exposure to allergens or irritants. Living in substandard housing often constitutes excess exposure to indoor allergens and pollutants. Allergens associated with dust mites (DM) and cockroaches (CR) are probably important in both onset and worsening of asthma symptoms for children who are chronically exposed to these agents. Young children spend a great deal of time on or near the floor where these allergens are concentrated in dust. Of children (2 to 10 years of age) living in metropolitan Washington, DC, 60% were found to be sensitive to CR and 72% were allergic to DM. Exposure to tobacco smoke contributes to onset of asthma earlier in life and is a risk factor for asthma morbidity. Since disparity of asthma mortality and morbidity among minority children in urban centers is closely linked to socioeconomic status and poverty, measures to reduce exposure to environmental allergens and irritants and to eliminate barriers to access to health care are likely to have a major positive impact. Interventions for children in urban centers must focus on prevention of asthma symptoms and promotion of wellness.
PMCID: PMC1518936  PMID: 8549491
6.  Asthma and the home environment of low-income urban children: Preliminary findings from the seattle-king county healthy homes project 
Objectives
Childhood asthma is a growing public health concern in low-income urban communities. Indoor exposure to asthma triggers has emerged as an important cause of asthma exacerbations. We describe indoor environmental conditions related to asthma triggers among a low-income urban population in Seattle/King County, Washington, as well as caregiver knowledge and resources related to control of these triggers.
Methods
Data are obtained from in-person, structured, closed-end interviews with the caretakers of children aged 4–12 years with persistent asthma living in households with incomes less than 200% of poverty. Additional information is collected during a home inspection. The children and their caregivers are participants in the ongoing Seattle-King County Healthy Homes Project, a randomized controlled trial of an intervention to empower low-income families to reduce exposure to indoor asthma triggers. We report findings on the conditions of the homes prior to this intervention among the first 112 enrolled households.
Results
A smoker was present in 37.5% of homes. Mold was visible in 26.8% of homes, water damage was present in 18.6% of homes, and damp conditions occurred in 64.8% of households, while 39.6% of caregivers were aware that excessive moisture can increase exposures to allergens. Dust-trapping reservoirs were common; 76.8% of children's bedrooms had carpeting. Cockroach infestation in the past 3 months was reported by 23.4% of caregivers, while 57.1% were unaware of the association of roaches and asthma. Only 19.8% of the children had allergy-control mattress covers.
Conclusions
Many low-income urban children with asthma in King County live in indoor environments that place them at substantial risk of ongoing exposure to asthma triggers. Substandard housing and lack of resources often underlie these exposures. Initiatives involving health educators, outreach workers, medical providers, health care insurers, housing agencies, and elected officials are needed to reduce these exposures.
doi:10.1007/BF02350962
PMCID: PMC3456608  PMID: 10741842
Asthma; Child; Indoor Air Pollution; Indoor Environment; Knowledge/Behaviors; Low-Income Populations
7.  Healthy Homes University: A Home-Based Environmental Intervention and Education Program for Families with Pediatric Asthma in Michigan 
Public Health Reports  2011;126(Suppl 1):14-26.
Environmental conditions within the home can exacerbate asthmatic children's symptoms. To improve health outcomes among this group, we implemented an in-home environmental public health program—Healthy Homes University—for low-income families in Lansing, Michigan, from 2005 to 2008. Families received four visits during a six-month intervention. Program staff assessed homes for asthma triggers and subsequently provided products and services to reduce exposures to cockroaches, dust mites, mold, tobacco smoke, and other triggers. We also provided asthma education that included identification of asthma triggers and instructions on specific behaviors to reduce exposures. Based on self-reported data collected from 243 caregivers at baseline and six months, the impact of asthma on these children was substantially reduced, and the proportion who sought acute unscheduled health care for their asthma decreased by more than 47%.
PMCID: PMC3072899  PMID: 21563708
8.  Implementation of Evidence-based Asthma Interventions in Post-Katrina New Orleans: The Head-off Environmental Asthma in Louisiana (HEAL) Study 
Environmental Health Perspectives  2012;120(11):1607-1612.
Background: Childhood asthma morbidity and mortality in New Orleans, Louisiana, is among the highest in the nation. In August 2005, Hurricane Katrina created an environmental disaster that led to high levels of mold and other allergens and disrupted health care for children with asthma.
Objectives: We implemented a unique hybrid asthma counselor and environmental intervention based on successful National Institutes of Health asthma interventions from the National Cooperative Inner City Asthma (NCICAS) and Inner-City Asthma (ICAS) Studies with the goal of reducing asthma symptoms in New Orleans children after Hurricane Katrina.
Methods: Children (4–12 years old) with moderate-to-severe asthma (n = 182) received asthma counseling and environmental intervention for approximately 1 year. HEAL was evaluated employing several analytical approaches including a pre–post evaluation of symptom changes over the entire year, an analysis of symptoms according to the timing of asthma counselor contact, and a comparison to previous evidence-based interventions.
Results: Asthma symptoms during the previous 2 weeks decreased from 6.5 days at enrollment to 3.6 days at the 12-month symptom assessment (a 45% reduction, p < 0.001), consistent with changes observed after NCICAS and ICAS interventions (35% and 62% reductions in symptom days, respectively). Children whose families had contact with a HEAL asthma counselor by 6 months showed a 4.09-day decrease [95% confidence interval (CI): 3.25 to 4.94-day decrease] in symptom days, compared with a 1.79-day decrease (95% CI: 0.90, 2.67) among those who had not yet seen an asthma counselor (p < 0.001).
Conclusions: The novel combination of evidence-based asthma interventions was associated with improved asthma symptoms among children in post-Katrina New Orleans. Post-intervention changes in symptoms were consistent with previous randomized trials of NCICAS and ICAS interventions.
doi:10.1289/ehp.1104242
PMCID: PMC3556603  PMID: 22894795
asthma case management; asthma counselor; asthma morbidity; environmental intervention; Hurricane Katrina; indoor allergens; mold
9.  Asthma is not enough: Continuation of smoking among parents with an asthmatic child 
BACKGROUND:
Ideally, on diagnosis of asthma in a child, parents are counselled to decrease environmental tobacco smoke exposure to their children.
OBJECTIVE:
To determine whether a diagnosis of asthma in children altered parental smoking behaviour toward a reduction in environmental tobacco smoke exposure.
METHODS:
In 2002/2003, a survey was sent to 12,556 households with children born in 1995 in Manitoba. Parents were asked whether their seven-year-old child had asthma, and whether smokers were present in the home in 1995 and/or currently. The likelihood (OR) of a change in parental smoking behaviour was determined according to the presence of asthma in their child, a family history of asthma, the location of residence (rural or urban) and their socioeconomic status.
RESULTS:
A total of 3580 surveys (28.5%) were returned. The overall prevalence of parental smoking in 1995 and 2002/2003 was 32.2% and 23.4%, respectively (31.9%/23.2% and 32.3%/23.6% in rural and urban environments, respectively). In 2002/2003, the prevalence of parental smoking in homes with asthmatic children was 29.8%. Parents were not more likely to quit smoking (OR=1.01, 95% CI 0.66 to 1.54) or smoke outside (OR=1.02, 95% CI 0.56 to 1.83) if their child developed asthma. Parental smoking behaviour (quit smoking or smoked outside) did not change if there was a positive family history of asthma (OR=1.04, 95% CI 0.78 to 1.37), if they lived in a rural or urban location (OR=0.94, 95% CI 0.71 to 1.23), or if they were from a low- or high-income household (OR=1.12, 95% CI 0.85 to 1.47).
CONCLUSIONS:
The likelihood of altering parental smoking behaviour occurred independently of a diagnosis of asthma in their child, a family history of asthma, the location of residence and their socioeconomic status.
PMCID: PMC2676408  PMID: 17885695
Asthma; Children; Environmental tobacco smoke; Parents; Smoking cessation
10.  Integrating Asthma Education and Smoking Cessation for Parents: Financial Return on Investment 
Pediatric pulmonology  2012;47(10):950-955.
Summary
Background
Caregivers who smoke and have children with asthma are an important group for intervention. Home-based interventions successfully reduce asthma morbidity, yet are costly. This study evaluated the financial return on investment (ROI) of the Parents of Asthmatics Quit Smoking (PAQS) program, a combined asthma education and smoking cessation intervention.
Methods
Participants included caregivers (n = 224) that smoked, had a child with asthma, and were enrolled in a Medicaid managed care plan. Participants received nurse-delivered asthma education and smoking counseling in three home visits. Program implementation costs were estimated, and health care expenses were obtained from insurance claims data 12 months pre- and 12 months post intervention. ROI was calculated for all participants, children < 6 years, children 6–18 years, and children with moderate/severe persistent asthma.
Results
Total program implementation cost was $34,481. After intervention, there was increased mean annual refills of beta-agonist (0.51 pre, 1.64 post; p<0.001), and controller medications (0.65 pre, 2.44 post; p<0.001). Reductions were found in mean annual emergency department visits (0.33 pre, 0.14 post; p<0.001), hospitalizations (0.23 pre, 0.08 post; p<0.001), and outpatient visits (2.33 pre, 1.45 post, p<0.001). The program had negative ROI (−21.8%) for the entire sample. The ROI was positive (+106.9) for children < six years, negative (−150.3) for children 6–18, and negligible for moderate/severe persistent asthma (+6.9%).
Conclusion
PAQS was associated with increased medication use and decreased health care utilization. While the overall ROI for PAQS was negative, PAQS had a positive ROI for caregivers of young children with asthma.
doi:10.1002/ppul.22559
PMCID: PMC3407822  PMID: 22467563
Asthma; Pediatrics; Smoking Cessation; Education
11.  Increasing Adherence to Inhaled Steroids Among School Children: A Randomized Controlled Trial of School Based Supervised Asthma Therapy 
Pediatrics  2009;123(2):466-474.
Objective
Few patients take inhaled corticosteroids as recommended. This study aimed to determine the effectiveness of school-based supervised asthma therapy in improving asthma control. The primary hypothesis was that the supervised asthma therapy group would have a lower proportion of children experiencing an episode of poor asthma control (EPAC) each month compared to the usual care group.
Patients and Methods
Children were eligible if they had physician-diagnosed persistent asthma, the need for daily controller medication, and the ability to use a dry-powder inhaler and a PFM. The trial used a two-group randomized longitudinal design with 15 month follow-up. 290 children from 36 schools were randomly assigned to either: school-based supervised asthma therapy or usual care. Ninety-one percent of children were African American and 57% were male. Mean age was 11 years (SD = 2.1). An EPAC was defined as one or more of the following each month: 1) an absence from school due to respiratory illness/asthma; 2) average use of rescue medication more than two times per week (not including pre-exercise treatment); or 3) at least one red or yellow PFM reading.
Results
240 children completed the study. There were no differences in the likelihood of an EPAC between the baseline and follow-up period in the usual care group (p=0.77); however, among those in the supervised therapy group, the odds of experiencing an EPAC during the baseline period were 1.57 times the odds of experiencing an EPAC during the follow-up period (90% CI: 1.20, 2.06, p=0.006). GEE modeling revealed a marginally significant interaction between the intervention and time period (p=0.065) indicating that children in the supervised therapy group showed greater improvement in asthma control.
Conclusions
Supervised asthma therapy improves asthma control. Clinicians who have pediatric asthma patients with poor outcomes that may be due to non-adherence should consider supervised therapy.
doi:10.1542/peds.2008-0499
PMCID: PMC2782792  PMID: 19171611
asthma; child; anti-asthmatic drugs; schools
12.  Indoor air pollution and childhood asthma: effective environmental interventions. 
Environmental Health Perspectives  1995;103(Suppl 6):55-58.
Exposure to indoor air pollutants such as tobacco smoke and dust mites may exacerbate childhood asthma. Environmental interventions to reduce exposures to these pollutants can help prevent exacerbations of the disease. Among the most important interventions is the elimination of environmental tobacco smoke from the environments of children with asthma. However, the effectiveness of reducing asthmatic children's exposure to environmental tobacco smoke on the severity of their symptoms has not yet been systematically evaluated. Dust mite reduction is another helpful environmental intervention. This can be achieved by enclosing the child's mattresses, blankets, and pillows in zippered polyurethane-coated casings. Primary prevention of asthma is not as well understood. It is anticipated that efforts to reduce smoking during pregnancy could reduce the incidence of asthma in children. European studies have suggested that reducing exposure to food and house dust mite antigens during lactation and for the first 12 months of life diminishes the development of allergic disorders in infants with high total IgE in the cord blood and a family history of atopy. Many children with asthma and their families are not receiving adequate counseling about environmental interventions from health care providers or other sources.
PMCID: PMC1518930  PMID: 8549490
13.  Individual-level socioeconomic status is associated with worse asthma morbidity in patients with asthma 
Respiratory Research  2009;10(1):125.
Background
Low socioeconomic status (SES) has been linked to higher morbidity in patients with chronic diseases, but may be particularly relevant to asthma, as asthmatics of lower SES may have higher exposures to indoor (e.g., cockroaches, tobacco smoke) and outdoor (e.g., urban pollution) allergens, thus increasing risk for exacerbations.
Methods
This study assessed associations between adult SES (measured according to educational level) and asthma morbidity, including asthma control; asthma-related emergency health service use; asthma self-efficacy, and asthma-related quality of life, in a Canadian cohort of 781 adult asthmatics. All patients underwent a sociodemographic and medical history interview and pulmonary function testing on the day of their asthma clinic visit, and completed a battery of questionnaires (Asthma Control Questionnaire, Asthma Quality of Life Questionnaire, and Asthma Self-Efficacy Scale). General Linear Models assessed associations between SES and each morbidity measure.
Results
Lower SES was associated with worse asthma control (F = 11.63, p < .001), greater emergency health service use (F = 5.09, p = .024), and worse asthma self-efficacy (F = 12.04, p < .01), independent of covariates. Logistic regression analyses revealed that patients with <12 years of education were 55% more likely to report an asthma-related emergency health service visit in the last year (OR = 1.55, 95%CI = 1.05-2.27). Lower SES was not related to worse asthma-related quality of life.
Conclusions
Results suggest that lower SES (measured according to education level), is associated with several indices of worse asthma morbidity, particularly worse asthma control, in adult asthmatics independent of disease severity. Results are consistent with previous studies linking lower SES to worse asthma in children, and add asthma to the list of chronic diseases affected by individual-level SES.
doi:10.1186/1465-9921-10-125
PMCID: PMC2806364  PMID: 20017907
14.  Implementation of a community-based secondhand smoke reduction intervention for caregivers of urban children with asthma: process evaluation, successes and challenges 
Health Education Research  2012;28(1):141-152.
Many children, including those with asthma, remain exposed to secondhand smoke. This manuscript evaluates the process of implementing a secondhand smoke reduction counseling intervention using motivational interviewing (MI) for caregivers of urban children with asthma, including reach, dose delivered, dose received and fidelity. Challenges, strategies and successes in applying MI are highlighted. Data for 140 children (3–10 years) enrolled in the School Based Asthma Therapy trial, randomized to the treatment condition and living with one or more smoker, were analyzed. Summary statistics describe the sample, process measures related to intervention implementation, and primary caregiver (PCG) satisfaction with the intervention. The full intervention was completed by 79% of PCGs, but only 17% of other smoking caregivers. Nearly all (98%) PCGs were satisfied with the care study nurses provided and felt the program might be helpful to others. Despite challenges, this intervention was feasible and well received reaching caregivers who were not actively seeking treatment for smoking cessation or secondhand smoke reduction. Anticipating the strategies required to implement such an intervention may help promote participant engagement and retention to enhance the program’s ultimate success.
doi:10.1093/her/cys070
PMCID: PMC3549585  PMID: 22717938
15.  Improving Care for Urban Children with Asthma: Design and Methods of the School-Based Asthma Therapy (SBAT) Trial 
The School Based Asthma Therapy (SBAT) trial builds on a pilot study in which we found that school-based administration of preventive asthma medications for inner-city children reduced asthma symptoms. However, the beneficial effects of this program were seen only among children not exposed to environmental tobacco smoke (ETS). The current study is designed to establish whether this intervention can be enhanced by more stringent adherence to asthma guidelines through the addition of symptom-based medication dose adjustments, and whether smoke-exposed children benefit from the intervention when it is combined with an ETS reduction program. The intervention consists of both administration of preventive asthma medications in school (with dose adjustments according to NHLBI guidelines) and a home-based ETS reduction program utilizing motivational interviewing principles. This paper describes the methodology, conceptual framework, and lessons learned from the SBAT trial. Results of this study will help to determine whether this type of comprehensive school-based program can serve as a model to improve care for urban children and reduce disparities.
doi:10.1080/02770900701854908
PMCID: PMC2605580  PMID: 18446591
asthma; children; preventive care; schools; environmental tobacco smoke; adherence
16.  Results from a community-based program evaluating the effect of changing smoking status on asthma symptom control 
BMC Public Health  2012;12:293.
Background
Cigarette smoking has been associated with accelerated decline in lung function, increased health services use and asthma severity in patients with asthma. Previous studies have provided insight into how smoking cessation improves lung function among asthma patients, however, fail to provide measurable asthma symptom-specific outcomes after smoking cessation. The objective of this study was to measure the effect of changing smoking status on asthma symptom control and health services use in adults with asthma.
Methods
The study was conducted in eight primary care practices across Ontario, Canada participating in a community-based, participatory, and evidence-based Asthma Care Program. Patients aged 18 to 55 identified with physician-diagnosed mild to moderate asthma were recruited. In addition to receiving clinical asthma care, participants were administered a questionnaire at baseline and 12-month follow-up visits to collect information on demographics, smoking status, asthma symptoms and routine health services use. The effect of changing smoking status on asthma symptom control was compared between smoking groups using Chi-square and Fisher’s exact tests where appropriate. Mixed effect models were used to measure the impact of the change in smoking status on asthma symptom and health services use while adjusting for covariates.
Results
This study included 519 patients with asthma; 11% of baseline smokers quit smoking while 4% of baseline non-smokers started smoking by follow-up. Individuals who quit smoking had 80% lower odds of having tightness in the chest (Odds ratio (OR) = 0.21, 95% CI: 0.06, 0.82) and 76% lower odds of night-time symptoms (OR = 0.24, 95% CI: 0.07, 0.85) compared to smokers who continued to smoke. Compared to those who remained non-smokers, those who had not been smoking at baseline but self-reported as current smoker at follow-up had significantly higher odds of chest tightness (OR = 1.36, 95% CI: 1.10, 1.70), night-time symptoms (OR = 1.55, 95% CI: 1.09, 2.20), having an asthma attack in the last six months (OR = 1.43, 95% CI: 1.17, 1.75) and visiting a walk-in clinic for asthma (OR = 4.57, 95% CI: 1.44, 14.49).
Conclusions
This study provides practitioners measurable and clinically important findings that associate smoking cessation with improved asthma control. Health practitioners and asthma programs can use powerful education messages to emphasize the benefits of smoking cessation as a priority to current smokers.
doi:10.1186/1471-2458-12-293
PMCID: PMC3464678  PMID: 22520046
17.  Effects of active tobacco smoking on the prevalence of asthma-like symptoms in adolescents 
The prevalence of asthma in adolescents markedly varies between different localities as found by the International Study of Asthma and Allergies in Childhood (ISAAC) and this may be due to environmental factors. Although tobacco smoke exposure is related to an increase in the prevalence of asthma, there is lack of information on that respect in children from developing countries, where active tobacco smoking usually starts early in adolescence. This study was undertaken to assess the effect of tobacco smoking on the prevalence of asthma symptoms in a random sample of 4738 adolescents aged 13.4 ± 1.05 years who responded the ISAAC video questionnaires plus questions on tobacco smoking. The prevalence of tobacco smoking in the last 12 months was 16.2%, with significant female predominance. The persistent smokers had a significantly higher prevalence of asthma-like symptoms ever and in the last 12 months (wheezing, wheezing with exercise, nocturnal wheezing, severe wheezing, and dry nocturnal cough) than ex-smokers and nonsmokers. More than 27% of asthma symptoms in our adolescents are attributable to active tobacco consumption (population attributable risk). This study strongly suggests that potent and more effective campaigns against tobacco smoking should be implemented in developing countries, where active tobacco smoking is dramatically increasing in children.
PMCID: PMC2692110  PMID: 18044067
asthma; prevalence; ISAAC; tobacco; video questionnaires
18.  Screening for Environmental Tobacco Smoke Exposure among Inner City Children with Asthma 
Pediatrics  2008;122(6):1277-1283.
Background
Environmental tobacco smoke (ETS) causes increased morbidity among children with asthma, however pediatricians do not consistently screen and counsel families of asthmatic children regarding ETS. An index score based on parent report of exposure could help providers efficiently screen for ETS.
Objective
1) To develop an index measure of ETS based on parent self-report of smoking behaviors; 2) To determine whether the index score is associated with children’s present and future cotinine levels.
Methods
Data were drawn from a community intervention for inner-city children with persistent asthma (n=226, response rate 72%). Measures of child salivary cotinine and parent self-reported ETS-related behaviors were obtained at baseline and 7–9 months later. To develop the index score, we used a 15-fold cross-validation method on 70% of our data that considered combinations of smoke exposure variables, controlling for demographics. We chose the most parsimonious model that minimized the mean square predictive error. The resulting index score included primary caregiver smoking and home smoking ban status. We validated our model on the remaining 30% of data. ANOVA and multivariate analyses were used to determine the association of the index score with children’s cotinine levels.
Results
54% of asthmatic children lived with ≥1 smoker and 51% of caregivers reported a complete home smoking ban. The children’s mean baseline cotinine was 1.55ng/ml (range 0.0–21.3). Children’s baseline and follow-up cotinine levels increased as scores on the index measure increased. In a linear regression, the index score was significantly and positively associated with children’s cotinine measurements at baseline (p<.001, model R2=.37) and 7–9 months later (p<.001, R2=.38).
Conclusion
An index measure with combined information regarding primary caregiver smoking and household smoking restrictions helps to identify asthmatic children with the greatest exposure to ETS, and can predict children who will have elevated cotinine levels 7–9 months later.
doi:10.1542/peds.2008-0104
PMCID: PMC2597221  PMID: 19047246
Environmental tobacco smoke; asthma; children; primary care; screening
19.  Integrating Evidence for Managing Asthma in Patients Who Smoke 
Cigarette smoking among asthma patients is associated with worsening symptoms and accelerated decline in lung function. Smoking asthma is also characterized by increased levels of neutrophils and macrophages, and greater small airway remodeling, resulting in increased airflow obstruction and impaired response to corticosteroid therapy. As a result, smokers are typically excluded from asthma randomized controlled trials (RCTs). The strict inclusion/exclusion criteria used by asthma RCTs limits the extent to which their findings can be extrapolated to the routine care asthma population and to reflect the likely effectiveness of therapies in subgroups of particular clinical interest, such as smoking asthmatics. The inclusion of smokers in observational asthma studies and pragmatic trials in asthma provides a way of assessing the relative effectiveness of different treatment options for the management of this interesting clinical subgroup. Exploratory studies of possible treatment options for smoking asthma suggest potential utility in: prescribing higher-dose ICS; targeting the small airways of the lungs with extra-fine particle ICS formulations; targeting leukotreines, and possibly also combinations of these options. However, further studies are required. With the paucity of RCT data available, complementary streams of evidence (those from RCTs, pragmatic trials and observational studies) need to be combined to help guide judicious prescribing decisions in smokers with asthma.
doi:10.4168/aair.2014.6.2.114
PMCID: PMC3936038  PMID: 24587946
Smoking; asthma; leukotriene receptor antagonists (LTRAs); small airways; inhaled glucocorticosteroids (ICS); extra-fine particle
20.  Asthma in Hispanics 
Hispanic individuals trace their ancestry to countries that were previously under Spanish rule, including Mexico, large parts of Central and South America, and some Caribbean islands. Most—but not all—Hispanics have variable proportions of European, Amerindian, and African ancestry. Hispanics are diverse with regard to many factors, including racial ancestry, country of origin, area of residence, socioeconomic status, education, and access to health care. Recent findings suggest that there is marked variation in the prevalence, morbidity, and mortality of asthma in Hispanics in the United States and in Hispanic America. The reasons for differences in asthma and asthma morbidity among and within Hispanic subgroups are poorly understood but are likely due to the interaction between yet-unidentified genetic variants and other factors, including environmental tobacco smoke exposure, obesity, allergen exposure, and availability of health care. Barriers to optimal management of asthma in Hispanics in the United States and in Hispanic America include inadequate access to health care, suboptimal use of antiinflammatory medications, and lack of reference values for spirometric measures of lung function in many subgroups (e.g., Puerto Ricans). Future studies of asthma in Hispanics should include large samples of subgroups that are well characterized with regard to self-reported ethnicity, country of origin, place of birth, area of residence, and indicators of socioeconomic status. Because Hispanics are disproportionately represented among the poor in the United States, implementation of adequate access to health care and social reforms (e.g., improving housing conditions) would likely have a major impact on reducing asthma morbidity in this population.
doi:10.1164/rccm.200508-1232SO
PMCID: PMC2662985  PMID: 16210666
asthma; genetics; Hispanics; risk factors
21.  Working toward a Sustainable System of Asthma Care: Development of the School-Based Preventive Asthma Care Technology (SB-PACT) Trial 
The Journal of Asthma  2012;49(4):395-400.
Objective
We previously conducted the School Based Asthma Therapy trial to improve adherence to national asthma guidelines for urban children through directly observed administration of preventive asthma medications in school. The trial successfully improved outcomes among these children; however several factors limit its potential for dissemination. To enhance sustainability, we subsequently developed a new model of care using web-based guides for efficient communications and integration within school and community systems. This paper describes the development of the School-Based Preventive Asthma Care Technology (SB-PACT) trial.
Method
We developed the SB-PACT web-based system based on stakeholder feedback, and conducted a pilot randomized trial with 100 children to establish its feasibility in facilitating preventive asthma care for high-risk children. The SB-PACT system represents a new model of care using web-based guides for asthma symptom screening, follow-up control assessments, and electronic communications with providers.
Result
We enrolled and successfully screened all children using the web-based system. Most providers used the electronic communication system without difficulty, and the majority of children in the intervention group received preventive medications through school as planned and dose adjustments as needed. Several challenges to implementation also were encountered.
Conclusion
This program is designed to promote sustainability of school-based asthma care, reduce program costs, and to ultimately succeed in a real-world setting. With further refinements, it has the potential to be implemented nationally in schools.
doi:10.3109/02770903.2012.669441
PMCID: PMC3381057  PMID: 22455402
asthma; school-based; technology; sustainability; preventive care
22.  Lessons Learned for the Study of Childhood Asthma from the Centers for Children’s Environmental Health and Disease Prevention Research 
Environmental Health Perspectives  2005;113(10):1430-1436.
The National Children’s Study will address, among other illnesses, the environmental causes of both incident asthma and exacerbations of asthma in children. Seven of the Centers for Children’s Environmental Health and Disease Prevention Research (Children’s Centers), funded by the National Institute of Environmental Health Sciences and the U.S. Environmental Protection Agency, conducted studies relating to asthma. The design of these studies was diverse and included cohorts, longitudinal studies of older children, and intervention trials involving asthmatic children. In addition to the general lessons provided regarding the conduct of clinical studies in both urban and rural populations, these studies provide important lessons regarding the successful conduct of community research addressing asthma. They demonstrate that it is necessary and feasible to conduct repeated evaluation of environmental exposures in the home to address environmental exposures relevant to asthma. The time and staff required were usually underestimated by the investigators, but through resourceful efforts, the studies were completed with a remarkably high completion rate. The definition of asthma and assessment of disease severity proved to be complex and required a combination of questionnaires, pulmonary function tests, and biologic samples for markers of immune response and disease activity. The definition of asthma was particularly problematic in younger children, who may exhibit typical asthma symptoms sporadically with respiratory infections without developing chronic asthma. Medications confounded the definition of asthma disease activity, and must be repeatedly and systematically estimated. Despite these many challenges, the Children’s Centers successfully conducted long-term studies of asthma.
doi:10.1289/ehp.7671
PMCID: PMC1281292  PMID: 16203259
asthma; children; Children’s Centers; environmental health; National Children’s Study; pregnancy
23.  Particle Concentrations and Effectiveness of Free-Standing Air Filters in Bedrooms of Children with Asthma in Detroit, Michigan 
Building and environment  2011;46(11):2303-2313.
Asthma can be exacerbated by environmental factors including airborne particulate matter (PM) and environmental tobacco smoke (ETS). We report on a study designed to characterize PM levels and the effectiveness of filters on pollutant exposures of children with asthma. 126 households with an asthmatic child in Detroit, Michigan, were recruited and randomized into control or treatment groups. Both groups received asthma education; the latter also received a free-standing high efficiency air filter placed in the child’s bedroom. Information regarding the home, emission sources, and occupant activities was obtained using surveys administered to the child's caregiver and a household inspection. Over a one-week period, we measured PM, carbon dioxide (CO2), environmental tobacco smoke (ETS) tracers, and air exchange rates (AERs). Filters were installed at midweek. Before filter installation, PM concentrations averaged 28 µg m−3, number concentrations averaged 70,777 and 1,471 L−1 in 0.3–1.0 and 1–5 µm size ranges, respectively, and the median CO2 concentration was 1,018 ppm. ETS tracers were detected in 23 of 38 homes where smoking was unrestricted and occupants included smokers and, when detected, PM concentrations were elevated by an average of 15 µg m−3. Filter use reduced PM concentrations by an average of 69 to 80%. Simulation models representing location conditions show that filter air flow, room volume and AERs are the key parameters affecting PM removal, however, filters can achieve substantial removal in even "worst" case applications. While PM levels in homes with asthmatic children can be high, levels can be dramatically reduced using filters.
doi:10.1016/j.buildenv.2011.05.012
PMCID: PMC3161201  PMID: 21874085
indoor environment; free-standing HEPA air filters; asthmatic children; particulate matter; exposures
24.  Ethnic Variability in Persistent Asthma After In Utero Tobacco Exposure 
Pediatrics  2011;128(3):e623-e630.
BACKGROUND:
The effects of in utero tobacco smoke exposure on childhood respiratory health have been investigated, and outcomes have been inconsistent.
OBJECTIVE:
To determine if in utero tobacco smoke exposure is associated with childhood persistent asthma in Mexican, Puerto Rican, and black children.
PATIENTS AND METHODS:
There were 295 Mexican, Puerto Rican, and black asthmatic children, aged 8 to 16 years, who underwent spirometry, and clinical data were collected from the parents during a standardized interview. The effect of in utero tobacco smoke exposure on the development of persistent asthma and related clinical outcomes was evaluated by logistic regression.
RESULTS:
Children with persistent asthma had a higher odds of exposure to in utero tobacco smoke, but not current tobacco smoke, than did children with intermittent asthma (odds ratio [OR]: 3.57; P = .029). Tobacco smoke exposure from parents in the first 2 years of life did not alter this association. Furthermore, there were higher odds of in utero tobacco smoke exposure in children experiencing nocturnal symptoms (OR: 2.77; P = .048), daily asthma symptoms (OR: 2.73; P = .046), and emergency department visits (OR: 3.85; P = .015) within the year.
CONCLUSIONS:
Exposure to tobacco smoke in utero was significantly associated with persistent asthma among Mexican, Puerto Rican, and black children compared with those with intermittent asthma. These results suggest that smoking cessation during pregnancy may lead to a decrease in the incidence of persistent asthma in these populations.
doi:10.1542/peds.2011-0640
PMCID: PMC3164096  PMID: 21859918
asthma; tobacco; Latino; African American; pregnancy
25.  PEDIATRIC ASTHMA: NATURAL HISTORY, ASSESSMENT AND TREATMENT 
Wheezing and childhood asthma are not synonymous but rather comprise a heterogeneous group of conditions that have different outcomes over the course of childhood. Most infants who wheeze have a transient condition associated with diminished airway function at birth and have no increased risk of asthma later in life. However, children with persistent wheezing throughout childhood and frequent exacerbations represent the main challenge today. Studying the natural history of asthma is important for the understanding and accurate prediction of the clinical course of different phenotypes. To date, a great improvement has been achieved in reducing the frequency of asthma symptoms. However, neither decreased environmental exposure nor controller treatment, as recommended by the recent national asthma education and prevention program, can halt the progression of asthma in childhood or the development of persistent wheezing phenotype. This review focuses on the recent studies that led to the current understanding of asthma phenotypes in childhood and the recommended treatments.
doi:10.1002/msj.20285
PMCID: PMC3172616  PMID: 21913196
asthma; pediatric; phenotypes; exacerbation; treatment; inhaled corticosteroid (ICS); short acting beta agonist (SABA); long acting beta agonist (LABA)

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