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1.  Factors Associated with Second Hand Smoke Exposure In Young Inner City Children with Asthma 
Objectives
To examine the association of social and environmental factors with levels of second hand smoke (SHS) exposure, as measured by salivary cotinine, in young inner city children with asthma.
Methods
We used data drawn from a home-based behavioral intervention for young high risk children with persistent asthma post emergency department (ED) treatment (N=198). SHS exposure was measured by salivary cotinine and caregiver report. Caregiver demographic and psychological functioning, household smoking behavior and asthma morbidity were compared with child cotinine concentrations. Chi-square and ANOVA tests and multivariate regression models were used to determine the association between cotinine concentrations with household smoking behavior and asthma morbidity.
Results
Over half (53%) of the children had cotinine levels compatible with SHS exposure and mean cotinine concentrations were high at 2.42 ng/ml (SD 3.2). The caregiver was the predominant smoker in the home (57%) and (63%) reported a total home smoking ban. Preschool age children, and those with caregivers reporting depressive symptoms and high stress had higher cotinine concentrations than their counterparts. Among children living in a home with a total home smoking ban, younger children had significantly higher mean cotinine concentration than older children (Cotinine: 3–5 year olds, 2.24 ng/ml (SD 3.5); 6–10 year olds, 0.63 ng/ml (SD 1.0); p <0.05). In multivariate models, the factors most strongly associated with high child cotinine concentrations were increased number of household smokers (β = 0.24) and younger child age (3–5 years) (β = 0.23; P <0.001, R2 = 0.35).
Conclusion
Over half of young inner-city children with asthma were exposed to second hand smoke and caregivers are the predominant household smoker. Younger children and children with depressed and stressed caregivers are at significant risk of smoke exposures, even when a household smoking ban is reported. Further advocacy for these high-risk children is needed to help caregivers quit and to mitigate smoke exposure.
doi:10.3109/02770903.2011.576742
PMCID: PMC3113681  PMID: 21545248
asthma; children; cotinine; second hand smoke
2.  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
3.  Asthma randomized trial of indoor wood smoke (ARTIS): Rationale and Methods 
Contemporary clinical trials  2012;33(5):1080-1087.
Background
Particulate matter (PM) exposures have been linked with poor respiratory health outcomes, especially among susceptible populations such as asthmatic children. Smoke from biomass combustion for residential home heating is an important source of PM in many rural or peri-urban areas in the United States.
Aim
To assess the efficacy of residential interventions that reduce indoor PM exposure from wood stoves and to quantify the corresponding improvements in quality of life and health outcomes for asthmatic children.
Design
The Asthma Randomized Trial of Indoor wood Smoke (ARTIS) study is an in-home intervention study of susceptible children exposed to biomass combustion smoke. Children, ages 7 to 17, with persistent asthma and living in homes that heat with wood stoves were recruited for this three arm randomized placebo-controlled trial. Two household-level intervention strategies, wood stove replacement and air filters, were compared to a sham air filter placebo. Improvement in quality of life of asthmatic children was the primary outcomes. Secondary asthma-related health outcomes included peak expiratory flow (PEF) and forced expiratory volume in first second (FEV1), biomarkers in exhaled breath condensate, and frequency of asthma symptoms, medication usage, and healthcare utilization. Exposure outcomes included indoor and outdoor PM2.5 mass, particle counts of several size fractions, and carbon monoxide.
Discussion
To our knowledge, this was the first randomized trial in the US to utilize interventions targeting residential wood stoves to assess the impact on indoor PM and health outcomes in a susceptible population.
Trial registration
ClincialTrials.gov NCT00807183.
doi:10.1016/j.cct.2012.06.006
PMCID: PMC3408844  PMID: 22735495
pediatric; asthma; home intervention; wood stove; filter; biomass combustion
4.  Reduction in Asthma Morbidity in Children as a Result of Home Remediation Aimed at Moisture Sources 
Environmental Health Perspectives  2006;114(10):1574-1580.
Objective
Home dampness and the presence of mold and allergens have been associated with asthma morbidity. We examined changes in asthma morbidity in children as a result of home remediation aimed at moisture sources.
Design
In this prospective, randomized controlled trial, symptomatic, asthmatic children (n = 62), 2–17 years of age, living in a home with indoor mold, received an asthma intervention including an action plan, education, and individualized problem solving. The remediation group also received household repairs, including reduction of water infiltration, removal of water-damaged building materials, and heating/ventilation/air-conditioning alterations. The control group received only home cleaning information. We measured children’s total and allergen-specific serum immuno-globulin E, peripheral blood eosinophil counts, and urinary cotinine. Environmental dust samples were analyzed for dust mite, cockroach, rodent urinary protein, endotoxin, and fungi. The follow-up period was 1 year.
Results
Children in both groups showed improvement in asthma symptomatic days during the preremediation portion of the study. The remediation group had a significant decrease in symptom days (p = 0.003, as randomized; p = 0.004, intent to treat) after remodeling, whereas these parameters in the control group did not significantly change. In the postremediation period, the remediation group had a lower rate of exacerbations compared with control asthmatics (as treated: 1 of 29 vs. 11 of 33, respectively, p = 0. 003; intent to treat: 28.1% and 10.0%, respectively, p = 0.11).
Conclusion
Construction remediation aimed at the root cause of moisture sources and combined with a medical/behavioral intervention significantly reduces symptom days and health care use for asthmatic children who live in homes with a documented mold problem.
doi:10.1289/ehp.8742
PMCID: PMC1626393  PMID: 17035145
asthma; children; damp housing; home remediation; indoor mold
5.  A Longitudinal Study of Indoor Nitrogen Dioxide Levels and Respiratory Symptoms in Inner-City Children with Asthma 
Environmental Health Perspectives  2008;116(10):1428-1432.
Background
The effect of indoor nitrogen dioxide concentrations on asthma morbidity among inner-city preschool children is uncertain.
Objectives
Our goal was to estimate the effect of indoor NO2 concentrations on asthma morbidity in an inner-city population while adjusting for other indoor pollutants.
Methods
We recruited 150 children (2–6 years of age) with physician-diagnosed asthma from inner-city Baltimore, Maryland. Indoor air was monitored over a 72-hr period in the children’s bedrooms at baseline and 3 and 6 months. At each visit, the child’s caregiver completed a questionnaire assessing asthma symptoms over the previous 2 weeks and recent health care utilization.
Results
Children were 58% male, 91% African American, and 42% from households with annual income < $25,000; 63% had persistent asthma symptoms. The mean (± SD) in-home NO2 concentration was 30.0 ± 33.7 (range, 2.9–394.0) ppb. The presence of a gas stove and the use of a space heater or oven/stove for heat were independently associated with higher NO2 concentrations. Each 20-ppb increase in NO2 exposure was associated significantly with an increase in the number of days with limited speech [incidence rate ratio (IRR) = 1.15; 95% confidence interval (CI), 1.05–1.25], cough (IRR = 1.10; 95% CI, 1.02–1.18), and nocturnal symptoms (IRR = 1.09; 95% CI, 1.02–1.16), after adjustment for potential confounders. NO2 concentrations were not associated with increased health care utilization.
Conclusions
Higher indoor NO2 concentrations were associated with increased asthma symptoms in preschool inner-city children. Interventions aimed at lowering NO2 concentrations in inner-city homes may reduce asthma morbidity in this vulnerable population.
doi:10.1289/ehp.11349
PMCID: PMC2569107  PMID: 18941590
asthma; indoor pollutants; inner city; nitrogen dioxide; preschool
6.  Environmental Tobacco Smoke and Behaviors of Inner-City Children With Asthma 
Objective
To explore the relationship between environmental tobacco smoke (ETS) exposure and behavior among inner-city children with significant asthma.
Methods
We analyzed baseline data for 200 children 4 to 10 years old who were enrolled in an asthma program. Environmental tobacco smoke exposure was measured by the child’s salivary cotinine level. Caregivers completed the 28-item Behavior Problem Index (BPI). Positive responses were summed for a total BPI score, and children with scores >14 were considered to have significant behavior problems. We conducted Student t tests and multivariate regression analyses to determine the association of children’s cotinine levels with BPI scores.
Results
Overall, 56% of children were male, 65% were black, and 72% had Medicaid. Mean cotinine level was 1.47 ng/mL. Overall, 30% of children had total BPI scores >14. Children with cotinine values >1.47 ng/mL had significantly higher scores compared with children with lower cotinine values on total BPI (12.5 vs 10.2), as well as externalizing (9.0 vs 7.2), antisocial (2.3 vs 1.7), and immature (2.1 vs 1.6) subscales. In a multivariate model, log cotinine remained independently associated with externalizing (P = .04), headstrong (P = .04), and antisocial behavior (P = .04).
Conclusions
Cotinine levels are independently associated with problem behaviors among this sample of urban children with asthma.
doi:10.1016/j.ambp.2008.04.002
PMCID: PMC2597107  PMID: 18922501
behavior; childhood asthma; environmental smoke exposure; inner-city
7.  Indoor Air Pollution and Asthma in Children 
The purpose of this article is to review indoor air pollution factors that can modify asthma severity, particularly in inner-city environments. While there is a large literature linking ambient air pollution and asthma morbidity, less is known about the impact of indoor air pollution on asthma. Concentrating on the indoor environments is particularly important for children, since they can spend as much as 90% of their time indoors. This review focuses on studies conducted by the Johns Hopkins Center for Childhood Asthma in the Urban Environment as well as other relevant epidemiologic studies. Analysis of exposure outcome relationships in the published literature demonstrates the importance of evaluating indoor home environmental air pollution sources as risk factors for asthma morbidity. Important indoor air pollution determinants of asthma morbidity in urban environments include particulate matter (particularly the coarse fraction), nitrogen dioxide, and airborne mouse allergen exposure. Avoidance of harmful environmental exposures is a key component of national and international guideline recommendations for management of asthma. This literature suggests that modifying the indoor environment to reduce particulate matter, NO2, and mouse allergen may be an important asthma management strategy. More research documenting effectiveness of interventions to reduce those exposures and improve asthma outcomes is needed.
doi:10.1513/pats.200908-083RM
PMCID: PMC3266016  PMID: 20427579
particulate matter; air pollution; pediatric; urban; bronchial hyperreactivity
8.  Households contaminated by environmental tobacco smoke: sources of infant exposures 
Tobacco Control  2004;13(1):29-37.
Objectives: To examine (1) whether dust and surfaces in households of smokers are contaminated with environmental tobacco smoke (ETS); (2) whether smoking parents can protect their infants by smoking outside and away from the infant; and (3) whether contaminated dust, surfaces, and air contribute to ETS exposure in infants.
Design: Quasi-experiment comparing three types of households with infants: (1) non-smokers who believe they have protected their children from ETS; (2) smokers who believe they have protected their children from ETS; (3) smokers who expose their children to ETS.
Setting: Homes of smokers and non-smokers.
Participants: Smoking and non-smoking mothers and their infants ⩽ 1 year.
Main outcome measures: ETS contamination as measured by nicotine in household dust, indoor air, and household surfaces. ETS exposure as measured by cotinine levels in infant urine.
Results: ETS contamination and ETS exposure were 5–7 times higher in households of smokers trying to protect their infants by smoking outdoors than in households of non-smokers. ETS contamination and exposure were 3–8 times higher in households of smokers who exposed their infants to ETS by smoking indoors than in households of smokers trying to protect their children by smoking outdoors.
Conclusions: Dust and surfaces in homes of smokers are contaminated with ETS. Infants of smokers are at risk of ETS exposure in their homes through dust, surfaces, and air. Smoking outside the home and away from the infant reduces but does not completely protect a smoker's home from ETS contamination and a smoker's infant from ETS exposure.
doi:10.1136/tc.2003.003889
PMCID: PMC1747815  PMID: 14985592
9.  Mechanistic Indicators of Childhood Asthma (MICA) Study: piloting an integrative design for evaluating environmental health 
BMC Public Health  2011;11:344.
Background
Asthma is a common complex disease responsible for considerable morbidity and mortality, particularly in urban minority populations. The Mechanistic Indicators of Childhood Asthma study was designed to pilot an integrative approach in children's health research. The study incorporates exposure metrics, internal dose measures, and clinical indicators to decipher the biological complexity inherent in diseases such as asthma and cardiovascular disease with etiology related to gene-environment interactions.
Methods/Design
205 non-asthmatic and asthmatic children, (9-12 years of age) from Detroit, Michigan were recruited. The study includes environmental measures (indoor and outdoor air, vacuum dust), biomarkers of exposure (cotinine, metals, total and allergen specific Immunoglobulin E, polycyclic aromatic hydrocarbons, volatile organic carbon metabolites) and clinical indicators of health outcome (immunological, cardiovascular and respiratory). In addition, blood gene expression and candidate SNP analyses were conducted.
Discussion
Based on an integrative design, the MICA study provides an opportunity to evaluate complex relationships between environmental factors, physiological biomarkers, genetic susceptibility and health outcomes.
Project approval
IRB Number 05-EPA-2637: The human subjects' research protocol was reviewed by the Institutional Review Board (IRB) of the University of North Carolina; the IRB of Westat, Inc., the IRB of the Henry Ford Health System; and EPA's Human Subjects' Research Review Official.
doi:10.1186/1471-2458-11-344
PMCID: PMC3112137  PMID: 21595901
10.  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
11.  In-Home Particle Concentrations and Childhood Asthma Morbidity 
Environmental Health Perspectives  2008;117(2):294-298.
Background
Although outdoor particulate matter (PM) has been linked to mortality and asthma morbidity, the impact of indoor PM on asthma has not been well established.
Objective
This study was designed to investigate the effect of in-home PM on asthma morbidity.
Methods
For a cohort of 150 asthmatic children (2–6 years of age) from Baltimore, Maryland, a technician deployed environmental monitoring equipment in the children’s bedrooms for 3-day intervals at baseline and at 3 and 6 months. Caregivers completed questionnaires and daily diaries during air sampling. Longitudinal data analyses included regression models with generalized estimating equations.
Results
Children were primarily African Americans (91%) from lower socioeconomic backgrounds and spent most of their time in the home. Mean (± SD) indoor PM2.5–10 (PM with aerodynamic diameter 2.5–10 μm) and PM2.5 (aerodynamic diameter < 2.5 μm) concentrations were 17.4 ± 21.0 and 40.3 ± 35.4 μg/m3. In adjusted models, 10-μg/m3 increases in indoor PM2.5–10 and PM2.5 were associated with increased incidences of asthma symptoms: 6% [95% confidence interval (CI), 1 to 12%] and 3% (95% CI, –1 to 7%), respectively; symptoms causing children to slow down: 8% (95% CI, 2 to 14%) and 4% (95% CI, 0 to 9%), respectively; nocturnal symptoms: 8% (95% CI, 1 to 14%) and 6% (95% CI, 1 to 10%), respectively; wheezing that limited speech: 11% (95% CI, 3 to 19%) and 7% (95% CI, 0 to 14%), respectively; and use of rescue medication: 6% (95% CI, 1 to 10%) and 4% (95% CI, 1 to 8%), respectively. Increases of 10 μg/m3 in indoor and ambient PM2.5 were associated with 7% (95% CI, 2 to 11%) and 26% (95% CI, 1 to 52%) increases in exercise-related symptoms, respectively.
Conclusions
Among preschool asthmatic children in Baltimore, increases in in-home PM2.5–10 and PM2.5 were associated with respiratory symptoms and rescue medication use. Increases in in-home and ambient PM2.5 were associated with exercise-related symptoms. Although reducing PM outdoors may decrease asthma morbidity, reducing PM indoors, especially in homes of inner-city children, may lead to improved asthma health.
doi:10.1289/ehp.11770
PMCID: PMC2649234  PMID: 19270802
air pollution; asthma; indoor; particulate matter; pediatric; urban
12.  Is the hair nicotine level a more accurate biomarker of environmental tobacco smoke exposure than urine cotinine? 
Study objective: The aim of this study was to compare the two biomarkers of exposure to environmental tobacco smoke (ETS); urine cotinine and hair nicotine, using questionnaires as the standard.
Design: A cross sectional study of children consecutively admitted to hospital for lower respiratory illnesses during the period of the study.
Settings: Three regional hospitals in the larger Wellington area, New Zealand.
Participants: Children aged 3–27 months and admitted to the above hospitals during August 1997 to October 1998. A total of 322 children provided 297 hair samples and 158 urine samples.
Main results: Hair nicotine levels were better able to discriminate the groups of children according to their household's smoking habits at home (no smokers, smoke only outside the home, smoke inside the house) than urine cotinine (Kruskall-Wallis; χ2=142.14, and χ2=49.5, respectively (p<0.0001)). Furthermore, hair nicotine levels were more strongly correlated with number of smokers in the house, and the number of cigarettes smoked by parents and other members of the child's households. Hair nicotine was better related to the questionnaire variables of smoking in a multivariate regression model (r2=0.55) than urine cotinine (r2=0.31).
Conclusions: In this group of young children, hair nicotine was a more precise biomarker of exposure to ETS than urine cotinine levels, using questionnaire reports as the reference. Both biomarkers indicate that smoking outside the house limits ETS exposure of children but does not eliminate it.
doi:10.1136/jech.56.1.66
PMCID: PMC1732006  PMID: 11801622
13.  Asthma and Ethnic Minorities: Socioeconomic Status and Beyond 
Purpose of review
We aim to discuss current insights into our understanding of the mechanisms by which socioeconomic status (SES) influences the prevalence and severity of asthma in ethnic minorities. In addition, we review potential risk factors for ethnic disparities in asthma that are not mediated by SES.
Recent findings
Exposures and factors correlated with ethnicity through SES (e.g. indoor and outdoor air quality, smoke exposure, and access to healthcare) are likely to explain a significant proportion of the observed ethnic differences in asthma morbidity. However, other factors correlated with ethnicity (e.g., genetic variation) can impact ethnic disparities in asthma independently of and/or interacting with SES-related factors.
Summary
SES is a rough marker of a variety of environmental/behavioral exposures and a very important determinant of differences in asthma prevalence and severity among ethnic minorities in the U.S. However, SES is unlikely to be the sole explanation for ethnic disparities in asthma, which may also be due to differences in genetic variation and gene-by-environment interactions among ethnic groups.
PMCID: PMC3920741  PMID: 19326508
Childhood asthma; asthma epidemiology; socioeconomic status; ethnicity; race; minorities
14.  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
15.  Changes in Environmental Tobacco Smoke Exposure and Asthma Morbidity Among Urban School Children 
Chest  2008;135(4):911-916.
Background:
Environmental tobacco smoke (ETS) exposure is associated with poor asthma outcomes in children. However, little is known about natural changes in ETS exposure over time in children with asthma and how these changes may affect health-care utilization. This article documents the relationship between changes in ETS exposure and childhood asthma morbidity among children enrolled in a clinical trial of supervised asthma therapy.
Methods:
Data for this analysis come from a large randomized clinical trial of supervised asthma therapy in which 290 children with persistent asthma were randomized to receive either usual care or supervised asthma therapy. No smoking cessation counseling or ETS exposure education was provided to caregivers; however, children were given 20 min of asthma education, which incorporated discussion of the avoidance of asthma triggers, including ETS. Asthma morbidity and ETS exposure data were collected from caregivers via telephone interviews at baseline and at the 1-year follow-up.
Results:
At baseline, 28% of caregivers reported ETS exposure in the home and 19% reported exposure outside of the primary household only. Among children whose ETS exposure decreased from baseline, fewer hospitalizations (p = 0.034) and emergency department (ED) visits (p ≤ 0.001) were reported in the 12 months prior to the second interview compared to the 12 months prior to the first interview. Additionally, these children were 48% less likely (p = 0.042) to experience an episode of poor asthma control (EPAC).
Conclusions:
This is the first study to demonstrate an association between ETS exposure reduction and fewer EPACs, respiratory-related ED visits, and hospitalizations. These findings emphasize the importance of ETS exposure reduction as a mechanism to improve asthma control and morbidity. Potential policy implications include supporting ETS reductions and smoking cessation interventions for parents and caregivers of children with asthma. Research to identify the most cost-effective strategy is warranted.
Trial registration:
Clinicaltrials.gov Identifier: NCT00110383
doi:10.1378/chest.08-1869
PMCID: PMC2763557  PMID: 19017893
asthma; children; environmental tobacco smoke; tobacco smoke pollution
16.  Personal Exposure to Household Particulate Matter, Household Activities and Heart Rate Variability among Housewives 
PLoS ONE  2014;9(3):e89969.
Background
The association between indoor air pollution and heart rate variability (HRV) has been well-documented. Little is known about effects of household activities on indoor air quality and HRV alteration. To investigate changes in HRV associated with changes in personal exposure to household particulate matter (PM) and household activities.
Methods
We performed 24-h continuous monitoring of electrocardiography and measured household PM exposure among 50 housewives. The outcome variables were log10-transformed standard deviation of normal-to-normal (NN) intervals (SDNN) and the square root of the mean of the sum of the squares of differences between adjacent NN intervals (r-MSSD). Household PM was measured as the mass concentration of PM with an aerodynamic diameter <2.5 µm (PM2.5). We used mixed-effects models to examine the association between household PM2.5 exposure and log10-transformed HRV indices.
Results
After controlling for potential confounders, an interquartile range change in household PM2.5 with 1- to 4-h mean was associated with 1.25–4.31% decreases in SDNN and 0.12–3.71% decreases in r-MSSD. Stir-frying, cleaning with detergent and burning incense may increase household PM2.5 concentrations and modify the effects of household PM2.5 on HRV indices among housewives.
Conclusions
Indoor PM2.5 exposures were associated with decreased SDNN and r-MSSD among housewives, especially during stir-frying, cleaning with detergent and burning incense.
doi:10.1371/journal.pone.0089969
PMCID: PMC3940710  PMID: 24594880
17.  Does passive smoking increase the frequency of health service contacts in children with asthma? 
Thorax  2001;56(1):9-12.
BACKGROUND—Passive smoking is a major cause of respiratory morbidity in children. However, few studies give accurate estimates of the health effects of passive smoking in children with asthma using an objective measure of exposure. The effects of passive smoking using salivary cotinine levels to measure exposure were investigated.
METHODS—A sample of 438 children aged 2-12 years with asthma who had a parent who smoked were recruited in Tayside and Fife, Scotland. Health service contacts for asthma, assessed from GP case records, were used as a proxy for morbidity.
RESULTS—A weak U-shaped relationship was found between the salivary cotinine level and health service contacts for asthma: compared with low cotinine levels those with moderate cotinine levels had a reduced contact rate (relative rate (RR) = 0.91, 95% confidence interval (CI) 0.80 to 1.05), whereas high cotinine levels were associated with an increased rate of contact (RR = 1.19, 95% CI 1.05 to 1.37). In contrast, a strong association was seen with the amount the parent reported smoking in front of the child: the higher the level the fewer visits were made for asthma (RR for everyday exposure = 0.66, 95% CI 0.56 to 0.77). This effect was not seen for non-respiratory visits. Demographic factors, age of child, and number of children in the family all had a powerful effect on the number of visits for asthma. The parents' perception of asthma severity was associated with visit frequency independent of actual severity (derived from drug treatment).
CONCLUSION—High levels of parental smoking in the home are associated with a reduction in health care contacts for asthma. This could be due to a lack of awareness of asthma symptoms among heavy smokers or a reluctance to visit the GP. Children with asthma who have parents who smoke heavily may not be receiving adequate management.


doi:10.1136/thorax.56.1.9
PMCID: PMC1745908  PMID: 11120897
18.  Household levels of nitrogen dioxide and pediatric asthma severity 
Epidemiology (Cambridge, Mass.)  2013;24(2):320-330.
Background
Adverse respiratory effects in children with asthma are associated with exposures to nitrogen dioxide (NO2). Levels indoors can be much higher than outdoors. Primary indoor sources of NO2 are gas stoves, which are used for cooking by one-third of US households. We investigated effects of indoor NO2 exposure on asthma severity among an ethnically and economically diverse sample of children, controlling for season and indoor allergen exposure.
Methods
Children aged 5–10 years with active asthma (n=1,342), were recruited through schools in urban and suburban Connecticut and Massachusetts (2006–2009) for a prospective, year-long study with seasonal measurements of NO2 and asthma severity. Exposure to NO2 was measured passively for four, month-long, periods with Palmes tubes. Asthma morbidity was concurrently measured by a severity score and frequency of wheeze, night symptoms and use of rescue medication. We used adjusted, hierarchical ordered logistic regression models to examine associations between household NO2 exposure and health outcomes.
Results
Every 5 ppb increase in NO2 exposure above a threshold of 6 ppb was associated with a dose-dependent increase in risk of higher asthma severity score (odds ratio= 1.37 [95% confidence interval= 1.01 – 1.89]), wheeze (1.49 [1.09 – 2.03]), night symptoms (1.52 [1.16 – 2.00]) and rescue medication use (1.78 [1.33 – 2.38]).
Conclusions
Asthmatic children exposed to NO2 indoors, at levels well below the US Environmental Protection Agency outdoor standard (53 ppb), are at risk for increased asthma morbidity. Risks are not confined to inner-city children, but occur at NO2 concentrations common in urban and suburban homes.
doi:10.1097/EDE.0b013e318280e2ac
PMCID: PMC3686297  PMID: 23337243
19.  Motivation to Quit Smoking among Parents of Urban Children with Asthma 
Patient education and counseling  2009;79(2):152-155.
Objective
To identify factors associated with motivation to quit smoking among parents of urban children with asthma.
Methods
We analyzed data from parents who smoke and had a child enrolled in the School-Based Asthma Therapy trial. We assessed asthma symptoms, children's cotinine, and parent smoking behaviors. Motivation to quit smoking was assessed by a 10-point continuous measure (1=not at all motivated; 10=very motivated).
Results
209 parents smoked (39% of sample), and children's mean cotinine was 2.48 ng/ml. Motivation to quit was on average 6.9, and 47% of parents scored ≥8 on the scale. Parents who believed their child's asthma was not under good control, and parents who strongly agreed their child's asthma symptoms would decrease if they stopped smoking had higher motivation to quit compared to their counterparts (p <.05). In a multivariate analysis, parents who believed their child's asthma was not under control had more than twice the odds of reporting high motivation to quit.
Conclusion
Parents' perception of the risks of smoking to their child with asthma is associated with motivation to quit.
Practice Implications
Raising awareness about the effect of smoking and quitting on children's asthma might increase motivation to quit among parents.
doi:10.1016/j.pec.2009.09.004
PMCID: PMC2856779  PMID: 19796913
Asthma; parents; children; smoking cessation; motivation; environmental tobacco smoke
20.  Home Indoor Pollutant Exposures among Inner-City Children With and Without Asthma 
Environmental Health Perspectives  2007;115(11):1665-1669.
Background
Evidence for environmental causes of asthma is limited, especially among African Americans. To look for systematic differences in early life domestic exposures between inner-city preschool children with and without asthma, we performed a study of home indoor air pollutants and allergens.
Methods
Children 2–6 years of age were enrolled in a cohort study in East Baltimore, Maryland. From the child’s bedroom, air was monitored for 3 days for particulate matter ≤ 2.5 and ≤ 10 μm in aerodynamic diameter (PM2.5, PM10), nitrogen dioxide, and ozone. Median baseline values were compared for children with (n = 150) and without (n = 150) asthma. Housing characteristics related to indoor air pollution were assessed by caregiver report and home inspection. In addition, indoor allergen levels were measured in settled dust.
Results
Children were 58% male, 91% African American, and 88% with public health insurance. Housing characteristics related to pollutant exposure and bedroom air pollutant concentrations did not differ significantly between asthmatic and control subjects [median: PM2.5, 28.7 vs. 28.5 μg/m3; PM10, 43.6 vs. 41.4 μg/m3; NO2, 21.6 vs. 20.9 ppb; O3, 1.4 vs. 1.8 ppb; all p > 0.05]. Settled dust allergen levels (cat, dust mite, cockroach, dog, and mouse) were also similar in bedrooms of asthmatic and control children.
Conclusions
Exposures to common home indoor pollutants and allergens are similar for inner-city preschool children with and without asthma. Although these exposures may exacerbate existing asthma, this study does not support a causative role of these factors for risk of developing childhood asthma.
doi:10.1289/ehp.10088
PMCID: PMC2072822  PMID: 18008001
African American; air pollution; allergens; asthma; particulate matter; pediatric; urban
21.  Community Action Against Asthma 
BACKGROUND
Community Action Against Asthma (CAAA) is a community-based participatory research (CBPR) project that assesses the effects of outdoor and indoor air quality on exacerbation of asthma in children, and tests household- and neighborhood-level interventions to reduce exposure to environmental asthma triggers. Representatives of community-based organizations, academia, an integrated health system, and the local health department work in partnership on CAAA's Steering Committee (SC) to design and implement the project.
OBJECTIVE
To conduct a process evaluation of the CAAA community–academic partnership.
DESIGN
In-depth interviews containing open-ended questions were conducted with SC members. Analysis included established methods for qualitative data, including focused coding and constant comparison methods.
SETTING
Community setting in Detroit, Michigan.
PARTICIPANTS
Twenty-three members of the CAAA SC.
MEASUREMENTS
Common themes identified by SC members relating to the partnership's ability to achieve project goals and the successes and challenges facing the partnership itself.
MAIN RESULTS
Identified partnership accomplishments included: successful implementation of a complex project, identification of children with previously undiagnosed asthma, and diverse participation and community influence in SC decisions. Challenges included ensuring all partners' influence in decision-making, the need to adjust to “a different way of doing things” in CBPR, constraints and costs of doing CBPR felt by all partners, ongoing need for communication and maintaining trust, and balancing the needs of science and the community through intervention.
CONCLUSIONS
CBPR can enhance and facilitate basic research, but care must be given to trust issues, governance issues, organizational culture, and costs of participation for all organizations involved.
doi:10.1046/j.1525-1497.2003.20322.x
PMCID: PMC1494884  PMID: 12848839
community-based participatory research; asthma; partnership; process evaluation
22.  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
23.  Childhood asthma and indoor allergens in Native Americans in New York 
Environmental Health  2006;5:22.
Background
The objective of this study was to assess the correlation between childhood asthma and potential risk factors, especially exposure to indoor allergens, in a Native American population.
Methods
A case-control study of St. Regis Mohawk tribe children ages 2–14 years, 25 diagnosed with asthma and 25 controls was conducted. Exposure was assessed based on a personal interview and measurement of mite and cat allergens (Der p 1, Fel d 1) in indoor dust.
Results
A non-significant increased risk of childhood asthma was associated with self-reported family history of asthma, childhood environmental tobacco smoke exposure, and air pollution. There was a significant protective effect of breastfeeding against current asthma in children less than 14 years (5.2 fold lower risk). About 80% of dust mite and 15% of cat allergen samples were above the threshold values for sensitization of 2 and 1 μg/g, respectively. The association between current asthma and exposure to dust mite and cat allergens was positive but not statistically significant.
Conclusion
This research identified several potential indoor and outdoor risk factors for asthma in Mohawks homes, of which avoidance may reduce or delay the development of asthma in susceptible individuals.
doi:10.1186/1476-069X-5-22
PMCID: PMC1552054  PMID: 16859546
24.  Stress and Quality of Life in Caregivers of Inner-city Minority Children with Poorly Controlled Asthma 
Introduction
Caregiver quality of life (QOL) is known to influence asthma management behaviors. Risk factors for low caregiver QOL in families of inner-city children with asthma remain unclear. This study evaluated the interrelationships of asthma control, stress, and caregiver QOL.
Method
Data were analyzed from a home-based behavioral intervention for children with persistent asthma post asthma emergency department treatment. Caregivers reported on baseline demographics, asthma control, asthma management stress, life stress, and QOL. Hierarchical regression analysis examined the contributions of socio-demographic factors, asthma control, asthma management stress, and life stress in explaining caregiver QOL.
Results
Children (N=300) were primarily African-American (96%) and young (Mean age of 5.5 years). Caregivers were predominantly the biological mother (92%), single (70%), and unemployed (54%). Poor QOL was associated with higher caregiver education and number of children in the home, low asthma control, and increased asthma management stress and life stress. The model accounted for 28% of variance in caregiver QOL.
Discussion
Findings underscore the need for multi-faceted interventions to provide caregivers of children with asthma tools to cope with asthma management demands and contemporary life stressors.
doi:10.1016/j.pedhc.2011.09.009
PMCID: PMC3575578  PMID: 23414978
asthma; caregiver; stress; quality of life
25.  Cardio-respiratory outcomes associated with exposure to wildfire smoke are modified by measures of community health 
Environmental Health  2012;11:71.
Background
Characterizing factors which determine susceptibility to air pollution is an important step in understanding the distribution of risk in a population and is critical for setting appropriate policies. We evaluate general and specific measures of community health as modifiers of risk for asthma and congestive heart failure following an episode of acute exposure to wildfire smoke.
Methods
A population-based study of emergency department visits and daily concentrations of fine particulate matter during a wildfire in North Carolina was performed. Determinants of community health defined by County Health Rankings were evaluated as modifiers of the relative risk. A total of 40 mostly rural counties were included in the study. These rankings measure factors influencing health: health behaviors, access and quality of clinical care, social and economic factors, and physical environment, as well as, the outcomes of health: premature mortality and morbidity. Pollutant concentrations were obtained from a mathematically modeled smoke forecasting system. Estimates of relative risk for emergency department visits were based on Poisson mixed effects regression models applied to daily visit counts.
Results
For asthma, the strongest association was observed at lag day 0 with excess relative risk of 66%(28,117). For congestive heart failure the excess relative risk was 42%(5,93). The largest difference in risk was observed after stratifying on the basis of Socio-Economic Factors. Difference in risk between bottom and top ranked counties by Socio-Economic Factors was 85% and 124% for asthma and congestive heart failure respectively.
Conclusions
The results indicate that Socio-Economic Factors should be considered as modifying risk factors in air pollution studies and be evaluated in the assessment of air pollution impacts.
doi:10.1186/1476-069X-11-71
PMCID: PMC3506568  PMID: 23006928
Disparities and susceptibility; Air pollution; Climate change; Asthma; Congestive heart failure; Wildfires

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