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High Cotinine and Healthcare Utilization Disparities Among Low-Income Children

Published:October 29, 2020DOI:https://doi.org/10.1016/j.amepre.2020.06.018

      Introduction

      This study assesses the associations of child salivary cotinine, parent-reported smoking, and child tobacco smoke exposure with the number of child healthcare visits and hospital admissions over a 6-month period. This study also assesses the relationships between participant characteristics and child cotinine.

      Methods

      Longitudinal data were evaluated from a sample of 313 clinically ill children aged 0–9 years who lived with a smoker and presented to a pediatric emergency department or urgent care in 2016–2018. In 2020, cotinine measurements were log transformed, and Poisson and linear regression were performed.

      Results

      The majority of the children came from low-income homes (66.1%) and had public insurance/self-pay (95.5%). Child cotinine concentrations ranged from 0.1 to 332.0 ng/mL (geometric mean=4.8 ng/mL, 95% CI=4.1, 5.5). Poisson regression results indicated that each 1-unit increase of log-cotinine concentration was associated with an increase in pediatric emergency department visits over a 6-month period after the baseline visit, with an adjusted RR of 1.16 (95% CI=1.01, 1.34). Each 1-unit increase of log-cotinine concentration was associated with an increase in the frequency of hospital admissions over the 6-month period, with an adjusted RR of 1.50 (95% CI=1.08, 2.09). No differences were found between parent-reported smoking or child tobacco smoke exposure and healthcare utilization. Linear regression results indicated that children who were younger (β= −0.227, p=0.049), were White (geometric mean=5.5 ng/mL), had a medical history of prematurity (geometric mean=8.1 ng/mL), and had a winter baseline visit (geometric mean=6.5 ng/mL) had higher cotinine concentrations. Children living in apartments (geometric mean=5.5 ng/mL) and multiunit homes (geometric mean=5.5 ng/mL) had higher cotinine concentrations than those in single-family homes (geometric mean=3.6 ng/mL).

      Conclusions

      Routine biochemical screening could identify children who are in need of intensive tobacco smoke exposure reduction interventions.
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      REFERENCES

        • HHS
        The health consequences of involuntary exposure to tobacco smoke: a report of the Surgeon General.
        HHS, CDC, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, Atlanta, GA2006
        https://www.ncbi.nlm.nih.gov/books/NBK44324/
        Date accessed: February 1, 2020
        • HHS
        The health consequences of smoking—50 years of progress. A report of the Surgeon General.
        HHS, CDC, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, Atlanta, GA2014
        https://www.ncbi.nlm.nih.gov/books/NBK179276/
        Date accessed: February 1, 2020
        • Committee on Environmental Health, Committee on Substance Abuse, Committee on Adolescence, Committee on Native American Child Health
        From the American Academy of Pediatrics: policy statement–tobacco use: a pediatric disease [published correction appears in Pediatrics. 2010;125(4):861].
        Pediatrics. 2009; 124: 1474-1487https://doi.org/10.1542/peds.2009-2114
        • Farber HJ
        • Groner J
        • Walley S
        • Nelson K
        Section on Tobacco Control. Protecting children from tobacco, nicotine, and tobacco smoke.
        Pediatrics. 2015; 136: e1439-e1467https://doi.org/10.1542/peds.2015-3110
        • Merianos AL
        • Jandarov RA
        • Choi K
        • Mahabee-Gittens EM
        Tobacco smoke exposure disparities persist in U.S. children: NHANES 1999-2014.
        Prev Med. 2019; 123: 138-142https://doi.org/10.1016/j.ypmed.2019.03.028
        • Tsai J
        • Homa DM
        • Gentzke AS
        • et al.
        Exposure to secondhand smoke among nonsmokers - United States, 1988-2014.
        MMWR Morb Mortal Wkly Rep. 2018; 67: 1342-1346https://doi.org/10.15585/mmwr.mm6748a3
        • Wang Z
        • May SM
        • Charoenlap S
        • et al.
        Effects of secondhand smoke exposure on asthma morbidity and health care utilization in children: a systematic review and meta-analysis.
        Ann Allergy Asthma Immunol. 2015; 115: 396-401.e2https://doi.org/10.1016/j.anai.2015.08.005
        • Merianos AL
        • Jandarov RA
        • Mahabee-Gittens EM
        Association of secondhand smoke exposure with asthma symptoms, medication use, and healthcare utilization among asthmatic adolescents.
        J Asthma. 2019; 56: 369-379https://doi.org/10.1080/02770903.2018.1463379
        • Merianos AL
        • Jandarov RA
        • Mahabee-Gittens EM
        Secondhand smoke exposure and pediatric healthcare visits and hospitalizations.
        Am J Prev Med. 2017; 53: 441-448https://doi.org/10.1016/j.amepre.2017.03.020
        • Merianos AL
        • Odar Stough C
        • Nabors LA
        • Mahabee-Gittens EM
        Tobacco smoke exposure and health-care utilization among children in the United States.
        Am J Health Promot. 2018; 32: 123-130https://doi.org/10.1177/0890117116686885
        • Merianos AL
        • Jandarov RA
        • Mahabee-Gittens EM
        Adolescent tobacco smoke exposure, respiratory symptoms, and emergency department use.
        Pediatrics. 2018; 142e20180266https://doi.org/10.1542/peds.2018-0266
        • Jin Y
        • Seiber EE
        • Ferketich AK
        Secondhand smoke and asthma: what are the effects on healthcare utilization among children?.
        Prev Med. 2013; 57: 125-128https://doi.org/10.1016/j.ypmed.2013.05.003
        • Yao T
        • Sung HY
        • Wang Y
        • Lightwood J
        • Max W
        Healthcare costs of secondhand smoke exposure at home for U.S. children.
        Am J Prev Med. 2019; 56: 281-287https://doi.org/10.1016/j.amepre.2018.08.013
        • Rodríguez-Martínez CE
        • Sossa-Briceño MP
        • Castro-Rodriguez JA
        Predictors of hospitalization for asthma in children: results of a 1-year prospective study.
        Pediatr Pulmonol. 2014; 49: 1058-1064https://doi.org/10.1002/ppul.22936
        • Hill SC
        • Liang L
        Smoking in the home and children's health.
        Tob Control. 2008; 17: 32-37https://doi.org/10.1136/tc.2007.020990
        • Benowitz NL
        • Bernert JT
        • Foulds J
        • et al.
        Biochemical verification of tobacco use and abstinence: 2019 update.
        Nicotine Tob Res. 2020; 22: 1086-1097https://doi.org/10.1093/ntr/ntz132
        • Mahabee-Gittens EM
        • Ammerman RT
        • Khoury JC
        • et al.
        Healthy families: study protocol for a randomized controlled trial of a screening, brief intervention, and referral to treatment intervention for caregivers to reduce secondhand smoke exposure among pediatric emergency department patients.
        BMC Public Health. 2017; 17: 374https://doi.org/10.1186/s12889-017-4278-8
        • Mahabee-Gittens EM
        • Mazzella MJ
        • Doucette JT
        • et al.
        Comparison of liquid chromatography mass spectrometry and enzyme-linked immunosorbent assay methods to measure salivary cotinine levels in ill children.
        Int J Environ Res Public Health. 2020; 17: 1157https://doi.org/10.3390/ijerph17041157
        • Mahabee-Gittens EM
        • Merianos AL
        • Fulkerson PC
        • Stone L
        • Matt GE
        The association of environmental tobacco smoke exposure and inflammatory markers in hospitalized children.
        Int J Environ Res Public Health. 2019; 16: 4625https://doi.org/10.3390/ijerph16234625
        • Mahabee-Gittens EM
        • Merianos AL
        • Hoh E
        • Quintana PJ
        • Matt GE
        Nicotine on children's hands: limited protection of smoking bans and initial clinical findings.
        Tob Use Insights. 2019; 121179173X18823493https://doi.org/10.1177/1179173X18823493
        • Butz AM
        • Halterman JS
        • Bellin M
        • et al.
        Factors associated with second-hand smoke exposure in young inner-city children with asthma.
        J Asthma. 2011; 48: 449-457https://doi.org/10.3109/02770903.2011.576742
        • Hao S
        • Jin B
        • Shin AY
        • et al.
        Risk prediction of emergency department revisit 30 days post discharge: a prospective study [published correction appears in PLoS One. 2015;10(1):e0117633].
        PLoS One. 2014; 9e112944https://doi.org/10.1371/journal.pone.0112944
        • Bardach NS
        • Vittinghoff E
        • Asteria-Peñaloza R
        • et al.
        Measuring hospital quality using pediatric readmission and revisit rates.
        Pediatrics. 2013; 132: 429-436https://doi.org/10.1542/peds.2012-3527
        • Merianos AL
        • Dixon CA
        • Mahabee-Gittens EM
        Secondhand smoke exposure, illness severity, and resource utilization in pediatric emergency department patients with respiratory illnesses.
        J Asthma. 2017; 54: 798-806https://doi.org/10.1080/02770903.2016.1265127
      1. Mahabee-Gittens EM, Merianos AL, Dexheimer JW, et al. Utilization of a clinical decision support tool to reduce child tobacco smoke exposure in the urgent care setting. Pediatr Emerg Care. In press. Online October 19, 2018. https://doi.org/10.1097/pec.0000000000001646.

        • Kruse GR
        • Rigotti NA
        Routine screening of hospital patients for secondhand tobacco smoke exposure: a feasibility study.
        Prev Med. 2014; 69: 141-145https://doi.org/10.1016/j.ypmed.2014.09.017
        • Jenssen BP
        • Shelov ED
        • Bonafide CP
        • Bernstein SL
        • Fiks AG
        • Bryant-Stephens T
        Clinical decision support tool for parental tobacco treatment in hospitalized children.
        Appl Clin Inform. 2016; 7: 399-411https://doi.org/10.4338/aci-2015-12-ra-0169
        • Merianos AL
        • Dixon CA
        • Mahabee-Gittens EM
        Tobacco smoke exposure-related illnesses among pediatric emergency department patients.
        J Pediatr Health Care. 2017; 31: 161-166https://doi.org/10.1016/j.pedhc.2016.07.001
        • Wilson KM
        • Klein JD
        • Blumkin AK
        • Gottlieb M
        • Winickoff JP
        Tobacco-smoke exposure in children who live in multiunit housing.
        Pediatrics. 2011; 127: 85-92https://doi.org/10.1542/peds.2010-2046
        • McMillen R
        • Wilson K
        • Tanski S
        • Klein JD
        • Winickoff JP
        Adult attitudes and practices regarding smoking restrictions and child tobacco smoke exposure: 2000 to 2015.
        Pediatrics. 2018; 141: S21-S29https://doi.org/10.1542/peds.2017-1026F
        • King BA
        • Patel R
        • Babb SD
        • Hartman AM
        • Freeman A
        National and state prevalence of smoke-free rules in homes with and without children and smokers: two decades of progress.
        Prev Med. 2016; 82: 51-58https://doi.org/10.1016/j.ypmed.2015.11.010
        • U.S. Department of Housing and Urban Development
        Instituting smoke-free public housing.
        U.S. Department of Housing and Urban Development, Washington, DC2016 (Published May 12)
        • Ciaccio CE
        • Gurley-Calvez T
        • Shireman TI
        Indoor tobacco legislation is associated with fewer emergency department visits for asthma exacerbation in children.
        Ann Allergy Asthma Immunol. 2016; 117: 641-645https://doi.org/10.1016/j.anai.2016.10.005
        • Wagijo MA
        • Sheikh A
        • Duijts L
        • Been JV
        Reducing tobacco smoking and smoke exposure to prevent preterm birth and its complications.
        Paediatr Respir Rev. 2017; 22: 3-10https://doi.org/10.1016/j.prrv.2015.09.002
        • Islam JY
        • Keller RL
        • Aschner JL
        • Hartert TV
        • Moore PE
        Understanding the short- and long-term respiratory outcomes of prematurity and bronchopulmonary dysplasia.
        Am J Respir Crit Care Med. 2015; 192: 134-156https://doi.org/10.1164/rccm.201412-2142PP
        • Vanker A
        • Gie RP
        • Zar HJ
        The association between environmental tobacco smoke exposure and childhood respiratory disease: a review.
        Expert Rev Respir Med. 2017; 11: 661-673https://doi.org/10.1080/17476348.2017.1338949
        • Stotts AL
        • Northrup TF
        • Green C
        • et al.
        Reducing tobacco smoke exposure in high-risk infants: a randomized, controlled trial.
        J Pediatr. 2020; 218 (e1): 35-41https://doi.org/10.1016/j.jpeds.2019.10.070
        • Clinical Practice Guideline Treating Tobacco Use and Dependence 2008 Update Panel, Liaisons, and Staff
        A clinical practice guideline treating tobacco use and dependence 2008 update. A U.S. Public Health Service report.
        Am J Prev Med. 2008; 35: 158-176https://doi.org/10.1016/j.amepre.2008.04.009
        • Kruse CS
        • Stein A
        • Thomas H
        • Kaur H
        The use of electronic health records to support population health: a systematic review of the literature.
        J Med Syst. 2018; 42: 214https://doi.org/10.1007/s10916-018-1075-6
        • Liang H
        • Tsui BY
        • Ni H
        • et al.
        Evaluation and accurate diagnoses of pediatric diseases using artificial intelligence.
        Nat Med. 2019; 25: 433-438https://doi.org/10.1038/s41591-018-0335-9
        • Murphy SE
        Nicotine metabolism and smoking: ethnic differences in the role of P450 2A6.
        Chem Res Toxicol. 2017; 30: 410-419https://doi.org/10.1021/acs.chemrestox.6b00387