Secondhand smoke and asthma: What are the effects on healthcare utilization among children?

doi:10.1016/j.ypmed.2013.05.003

Preventive Medicine

Volume 57, Issue 2, August 2013, Pages 125-128

https://doi.org/10.1016/j.ypmed.2013.05.003 Get rights and content

Highlights

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In-home smoke exposure doubled the odds of hospitalization among kids with asthma.
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In-home smoke exposure was not related to hospitalization among non-asthmatics.
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In-home smoke exposure was related to emergency department visits.
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Asthma was associated with increased utilization of all healthcare services.

Abstract

Objective

This study aims to examine the associations between asthma, secondhand smoke exposure and healthcare utilization in a nationally representative sample of children.

Methods

Data from 5686 children aged 0–11 years were analyzed. Healthcare utilization, asthma diagnosis and demographic information came from the 2001 and 2006 Medical Expenditure Panel Surveys. Secondhand smoke exposure was measured during the 2000 and 2005 National Health Interview Surveys. Multivariable regression models were used to determine the association between secondhand smoke exposure, asthma diagnosis and healthcare utilization (hospitalizations, emergency department visits, outpatient visits and prescription medication use).

Results

Asthma modified the relationship between secondhand smoke exposure and hospitalizations, as exposure more than doubled the odds of hospitalization among children with asthma but had no effect on children without asthma. Secondhand smoke exposure increased the odds by 37% of emergency room visits (P < 0.001), but was not associated with outpatient visits or medication use. Children with asthma had a higher odds of utilizing all healthcare services (P < 0.001).

Conclusions

Secondhand smoke exposure was associated with a greater utilization of hospitals and emergency departments, and the effect on hospitalizations was most pronounced among children with asthma. Reducing secondhand smoke exposure would help to reduce the burden on the healthcare system, especially among children with asthma.

Introduction

Secondhand smoke exposure is known to cause adverse health outcomes among both children and adults (Bek et al., 1999, Boldo et al., 2010, U.S. Department of Health and Human Services, 2006). This association can be characterized as a dose–response relationship, with no minimum threshold for risk (Giovino, 2007). Children are more vulnerable to the negative effects of secondhand smoke, as their immune systems are not well developed (Schwartz, 2004). Childhood asthma has been repeatedly linked to secondhand smoke exposure (Burke et al., 2012, Elliot et al., 1998, Neuman et al., 2012, Palmer et al., 2006). Asthma prevalence has been increasing among children (CDC, 2011) and many studies have linked maternal smoking during pregnancy and secondhand smoke exposure during early childhood with asthma (Burke et al., 2012, Elliot et al., 1998, Neuman et al., 2012).

Children exposed to secondhand smoke appear to utilize the healthcare system at a greater rate (Florence et al., 2007, Hill and Liang, 2008, Levy et al., 2011, McBride et al., 1998). Hill and Liang (2008) provided evidence that secondhand smoke exposure increased the number of inpatient hospitalizations and emergency department visits. Levy et al. (2011) found that Medicaid-enrolled children who lived with smokers had increased healthcare costs, but after covariate adjustment this effect disappeared. Interestingly, Florence et al. (2007) found a negative association between household smoke exposure and any healthcare use among children. The inconsistent results may be due to differences in self-report versus medical provider reported outcome measures or the possibility that children who are exposed to indoor smoke may be less likely to access medical care. Given these inconsistent results, further research is needed to understand the association between secondhand smoke exposure and healthcare utilization.

While the results linking secondhand smoke exposure to increased healthcare utilization have been mixed, the evidence for asthma is consistent, with several studies demonstrating that asthma increases healthcare spending (Kamble and Bharmal, 2009, Lozano et al., 1999). The major contributors to the increased costs of asthma treatment are prescription medications and physician office visits.

Few studies have examined how secondhand smoke exposure influences asthma-related healthcare utilization. In a small study of children from one health maintenance organization, McBride et al. (1998) reported that children exposed to secondhand smoke were not more likely to purchase asthma-related prescriptions. Another study found that children who were exposed to secondhand smoke were less likely to use asthma-related healthcare services (Crombie et al., 2001).

Given the increasing trend of asthma prevalence among children and the substantial burden of secondhand smoke exposure, understanding the effects of secondhand smoke exposure, combined with asthma, on healthcare utilization is needed (Bek et al., 1999, Boldo et al., 2010, Braman, 2006, Giovino, 2007, U.S. Department of Health and Human Services, 2006). The objectives of this study were to examine the associations between asthma, secondhand smoke exposure and healthcare utilization in a nationally representative sample of children. Specifically, we wanted to determine whether the effect of secondhand smoke exposure on healthcare utilization was modified by asthma status. That is, is secondhand smoke exposure worse for children with asthma than for children without asthma or does it affect all children equally when examining healthcare utilization?

Section snippets

Data sources

In the current study, the sample consisted of children aged 0 to 11 years who were included in Panel 6, 2001 and Panel 11, 2006 of the Medical Expenditure Panel Survey (MEPS) Household Component (HC) (Agency for Healthcare Research and Quality, 2004, Agency for Healthcare Research and Quality, 2008). The MEPS is a national survey designed to collect information related to healthcare utilization and expenditures among the civilian, non-institutionalized household population in the US and is

Results

Table 1 summarized characteristics of children in the study by secondhand smoke exposure (n = 5686). Among children with complete information on smoking status, approximately 31.5% lived with at least one smoker in the household, and about 18.4% were exposed to secondhand smoke inside their homes during the previous year. Among households with in-home smoking, there was a greater prevalence of children who were African American, non-Hispanic, enrolled in public insurance or uninsured, and a

Discussion

To our knowledge, this is first study to examine the relationship between secondhand smoke exposure and asthma on healthcare utilization among children, using a nationally representative dataset. While we hypothesized that an asthma diagnosis would modify the relationship between secondhand smoke exposure and healthcare utilization, we only observed one interaction effect and that was on hospitalizations. The results suggested that among asthmatic children, secondhand smoke exposure more than

Conclusions

The present study found that exposure to secondhand smoke was associated with greater utilization of hospitals and emergency departments. The adverse impact of secondhand smoke appeared to be more serious among asthmatic children when examining hospitalizations. To better understand this association, future research should measure exposure to secondhand smoke directly, and examine the impact of parental attitudes on accessing healthcare and how they may differ between smokers and nonsmokers.

Conflict of interest statement

The authors declare that there are no conflicts of interests.

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Children exposed to tobacco smoke are at an increased risk of sudden infant death syndrome, lower respiratory illnesses, asthma, and ear infections.2 Healthy children with TSE are 1.4 times more likely to require an emergency room visit; children with asthma and TSE are 2.2 times more likely to be hospitalized than their nonexposed peers.3 Addressing tobacco and nicotine use by adolescents is crucial for the pediatrician because 90% of smokers start before the age of 18 years.2
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Although it is known that TSE levels are highest among children who are younger, impoverished, racially/ethnically diverse, and live in rented homes,5,6 limited information is available on the healthcare burden associated with TSE among this particular population. The majority of the work has relied on self-reported healthcare utilization, self-reported TSE, and biochemically measured TSE in children aged ≥3 years; focused on children with specific diagnoses (e.g., asthma); and used a comparison group of unexposed children.7,10–15 Although this research is beginning to fill an important gap, these relationships have not been biochemically validated or verified with electronic medical record (EMR) documentation among young children.
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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.
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).
Routine biochemical screening could identify children who are in need of intensive tobacco smoke exposure reduction interventions.
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We analyzed 2007-2012 National Health and Nutrition Examination Survey data (N = 2,482). Tobacco smoke exposure was assessed with serum cotinine and self-reported home exposure. We built multiple regression, logistic regression, and Poisson regression models, depending on the outcome.
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Similarly, mixed evidence for healthcare utilization among asthmatic children has been documented. In addition to studies that have shown a positive relationship between SHSe and healthcare visits and associated costs in children with asthma,8,9,18,19 an inconsistent association using salivary cotinine to measure SHSe was found, such that children with high cotinine levels had an elevated general practitioner contact rate, whereas children with moderate cotinine levels had a reduced rate of consultations for asthma.20 Although there are clear evidence-based guidelines that exhort pediatric practitioners to routinely screen for and provide SHSe counseling at every healthcare visit, rates of assistance for helping caregivers reduce their child’s SHSe remain low.21
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Secondhand smoke and asthma: What are the effects on healthcare utilization among children?

Highlights

Abstract

Objective

Methods

Results

Conclusions

Introduction

Section snippets

Data sources

Results

Discussion

Conclusions

Conflict of interest statement

Chest

Am. J. Prev. Med.

J. Allergy Clin. Immunol.

Ann. Epidemiol.

MEPS HC-070:2001 Full Year Consolidated Data File

MEPS HC-105:2006 Full Year Consolidated Data File

Household Component-National Health Interview Survey Linked File

The effect of passive smoking on pulmonary function during childhood

Postgrad. Med. J.

Health impact assessment of environmental tobacco smoke in European children: sudden infant death syndrome and asthma episodes

Public Health Rep.

Prenatal and passive smoke exposure and incidence of asthma and wheeze: systematic review and meta-analysis

Pediatrics

Vital signs: asthma prevalence, disease characteristics, and self-management education: United States, 2001–2009

MMWR Morb. Mortal. Wkly. Rep.

Does passive smoking increase the frequency of health service contacts in children with asthma?

Thorax

Maternal cigarette smoking is associated with increased inner airway wall thickness in children who die from sudden infant death syndrome

Am. J. Respir. Crit. Care Med.

Sample design of the Medical Expenditure Panel Survey Household Component, 1998–2007, Methodology Report No. 22