Chest
Volume 120, Issue 5, November 2001, Pages 1709-1722
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Occupational and Environmental Lung Disease
A Controlled Trial of an Environmental Tobacco Smoke Reduction Intervention in Low-Income Children With Asthma

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Study objectives

To determine the effectiveness of a cotinine-feedback, behaviorally based education intervention in reducing environmental tobacco smoke (ETS) exposure and health-care utilization of children with asthma.

Design

Randomized controlled trial of educational intervention vs usual care.

Setting

The pediatric pulmonary service of a regional pediatric hospital.

Participants

ETS-exposed, Medicaid/Medi-Cal-eligible, predominantly minority children who were 3 to 12 years old and who were seen for asthma in the hospital’s emergency, inpatient, and outpatient services departments (n = 87).

Intervention

Three nurse-led sessions employing behavior-changing strategies and basic asthma education and that incorporated repeated feedback on the child’s urinary cotinine level.

Measurements

The primary measurements were the urinary cotinine/creatinine ratio (CCR) and the number of acute asthma medical visits. The secondary measurements were number of hospitalizations, smoking restrictions in home, amount smoked, reported exposures of children, and asthma control.

Results

The intervention was associated with a significantly lower odds ratio (OR) for more than one acute asthma medical visit in the follow-up year, after adjusting for baseline visits (total visits, 87; OR, 0.32; p = 0.03), and a comparably sized but nonsignificant OR for one or more hospitalization (OR, 0.34; p = 0.14). The follow-up CCR measurement and the determination of whether smoking was prohibited inside the home strongly favored the intervention group (n = 51) (mean difference in CCR adjusted for baseline, −0.38; p = 0.26; n = 51) (60; OR [for proportion of subjects prohibiting smoking], 0.24; p = 0.11; n = 60).

Conclusions

This intervention significantly reduced asthma health-care utilization in ETS-exposed, low-income, minority children. Effects sizes for urine cotinine and proportion prohibiting smoking were moderate to large but not statistically significant, possibly the result of reduced precision due to the loss of patients to active follow-up. Improving ETS reduction interventions and understanding their mechanism of action on asthma outcomes requires further controlled trials that measure ETS exposure and behavioral and disease outcomes concurrently.

Section snippets

Interventions to Reduce ETS Exposure in Children

Legal, regulatory, and taxation changes, antismoking education programs, and smoking cessation assistance that incorporates nicotine replacement therapy have been associated with a reduction in the overall smoking rates in the United States, but reductions in the rates among young women, especially those with less education, have lagged behind those of men.13 Attempts to encourage nonvolunteer female smokers of childbearing age, including pregnant women and new mothers, to quit smoking or to

Eligibility:

Eligible children had the following characteristics: (1) age between 3 and 12 years; (2) had been examined because of acute asthma within the preceding year in the ED or urgent-care (Peds Plus) clinics and/or had been admitted to the inpatient service of the Valley Children’s Hospital (VCH) (VCH had been located in Fresno County, CA, until its new facility [in-patient services, ED, and specialty clinics] opened just across the Fresno-Madera County line in September 1998; the Peds Plus

Demographic Characteristics:

The sample consisted of approximately equal numbers of male and female children (Table 1). Approximately 44% of the sample was Hispanic and 38% was black. One third of the primary caregivers (28 of 87 caregivers) had not graduated from high school, and only 3 caregivers were college graduates. None of these demographic characteristics differed significantly between the intervention and control groups.

Smoking Practices:

The primary maternal caregiver (who was not always the child’s natural mother) was a smoker in

Discussion

We found that an educational intervention that emphasized reduction in ETS exposure and that used a variety of motivational, instructional, and other aides to promote behavior change was associated with significantly lower odds of having more than one acute medical visit for asthma (OR, 0.32; p = 0.03 [after controlling for baseline visits]) and also with a nonsignificant trend toward lower odds of hospitalization (OR, 0.34; p = 0.14). Using statistical bootstrap procedures, we confirmed that

Session 1

  • I.

    Introduction

    • a.

      Overview of the program

    • b.

      Identify problems that the parent has in managing the child’s asthma

  • II.

    Asthma pathophysiology

    • a.

      Explain how the lungs and breathing system work

    • b.

      Explain how this system is affected during and after an acute asthma episode

    • c.

      Explain inflammation and how to prevent and control it

    • d.

      Explain the effects of irritants/allergens on the lungs

    • e.

      Explain what it means to control asthma: environmental control and medications

    • f.

      Parental practice in explaining asthma to someone else

  • III.

    Understand

Acknowledgment

The authors acknowledge the contributions of the participating families and of Patricia Springer, RN, Pediatric Pulmonary Department, Monica Dibble, RRT, RPFT, and Terry Driscoll, RRT, CPFT, of the Pulmonary Function Laboratory, Eldon Swanson, Supervisor of the Immunology Laboratory, and Leo Baranda and Christine Davies of the Information Services Department, all of VCH, Madera, CA, for their assistance with the identification of patients, recruitment and follow-up, laboratory testing, and the

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  • Cited by (0)

    This research was supported by award No. U60/CCU912212 from the US Centers for Disease Control and Prevention and by the Medi-Cal Special Projects Section and Tobacco Control Section, California Department of Health Services.

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