Residential smoking restrictions are not associated with reduced child SHS exposure in a baseline sample of low-income, urban African Americans

doi:10.4236/health.2010.211188

Paper Menu >>

Journal Menu >>

Vol.2, No.11, 1264-1271 (2010)

doi:10.4236/health.2010.211188

Health

Residential smoking restrictions are not associated with

reduced child SHS exposure in a baseline sample of

low-income, urban African Americans

Bradley N. Collins1*, Jennifer K. Ibrahim1, Melbourne Hovell2, Natalie M. Tolley1, Uma S. Nair1,

Karen Jaffe1, David Zanis1, Janet Audrain-McGovern3

1Temple University Department of Public Health, Philadelphia, USA; *Corresponding Author: collinsb@temple.edu;

2San Diego State University Graduate School of Public Health, San Diego, USA;

3University of Pennsylvania Department of Psychiatry, Tobacco Use Research Center, Philadelphia, USA.

Received 3 September 2010; revised 15 September 2010; accepted 26 September 2010.

ABSTRACT

Second hand smoke exposure (SHSe) relates to

many chronic and acute illnesses. Low income

African American (AA) maternal smokers and

their children have disproportionately higher

tobacco-use and child SHSe-related morbidity

and mortality than other populations. While pub-

lic health officials promote residential smoking

restrictions to reduce SHSe and promote smo-

king cessation, little is known about the impact of

restrictions in changing smoking behavior and

SHSe in this population. Thus, the purpose of

this study was to examine associations between

residential smoking restrictions, maternal smo-

king, and young children’s SHSe in the context

of other factors known to influence low income

AA mothers’ smoking behavior. For this study,

we used cross-sectional, baseline data from 307

AA maternal smokers’ pre-treatment interviews

completed as part of a subsequent behavioral

counseling trial to reduce their young (< 4 years

old) children’s SHSe. Residential smoking re-

striction was dichotomized as 0 = no restric-

tions and 1 = some restrictions. Child urine co-

tinine provided a biomarker of SHSe. Mothers

reported cigarettes/day smoked, cigarettes/day

exposed to child, and intention to quit. Multi-

variate regressions modeled effects of restric-

tion as the primary predictor of smoking and

exposure outcomes. Maternal smoking patterns

such as cigarettes per day (β = 0.52, p < 0.001)

and years smoked (β = −0.11; p = 0.03) along

with presence of additional smokers in the

home (β = 0.10; p = 0.04), but not residential

restriction (β = −0.09, p = 0.10), predicted re-

ported SHSe. Restriction did not relate to baby

cotinine or maternal intention to quit. Thus, re-

sidential smoking restrictions may contribute to

efforts to reduce children’s SHSe and promote

maternal smoking change; but alone, may not

constitute a sufficient intervention to protect

children. Multi-level intervention approaches that

include SHSe-reduction residential smoking po-

licies plus support and cessation assistance for

smokers may be a necessary approach to smo-

ke-free home adoption and adherence.

Keywords: Home Smoking Policy; Second Hand

Smoke; Underserved Populations

1. PURPOSE

The World Health Organization and U.S. public health

agencies have concluded that secondhand smoke expo-

sure (SHSe) contributes to morbidity and mortality and

that there is no safe level of exposure [1,2]. SHSe is as-

sociated with a variety of acute and chronic health con-

sequences, with infants and toddlers across all racial and

socioeconomic groups bearing greater susceptibility to

acute consequences than other age groups [1,3-14]. Es-

timated medical expenditures for SHSe-attributable res-

piratory illness and pediatric emergency department ad-

missions alone exceeds $115 per child exposed annually,

or over $2.5 billion annually if extrapolated to U.S. chil-

dren of 3-11 years old [15-17].

While children’s SHSe remains a pressing public heal-

th concern in general, addressing SHSe in low-in-come,

minority populations is a more urgent need. Given evi-

dence that low income African Americans (AAs), suffer

greater SHSe-related morbidity and mortality compared to

other groups [18-29], many public health agencies, such

as the National Cancer Institute and Centers of Disease

B. N. Collins et al. / HEALTH 2 (2010) 1264-1271

1265

Control, cite the reduction of SHSe in such underserved

populations as a public health priority.

Reducing SHSe can lead to short-term and sustained

health benefits [30,31]. This evidence has accelerated the

trend to implement policies to reduce nonsmokers’ ex-

posure to SHS in public places and to protect young

children from SHSe in public housing and cars [32].

However, more research is needed to understand the

degree to which voluntary efforts to create residential

smoking restrictions influence children’s SHSe. The ra-

tionale behind efforts to reduce child SHSe in family

residences is based on evidence that tobacco smoked at

home, particularly mothers’ smoke, is the predominant

source of children’s SHSe [1,26,33-35].

Health officials have established practice guidelines

[36] to promote SHSe reduction, and some communities

have promoted smoke-free home adoption to protect

children [37]. Restricting residential smoking may bene-

fit children’s health and promote reduction in smokers’

daily smoking consumption [38]. Restrictions could pro-

duce even greater benefits among low income families

who are more likely to live in multiunit residences with

smaller square footage and experience higher rates of

overcrowding [39]. However, such communities experi-

ence greater barriers to smoking behavior change [40-

46]. Thus, the impact of residential smoking restrictions

on child SHSe and smokers’ daily consumption requires

further examination in low income communities.

Mechanisms by which workplace and public smoking

restrictions are successful will not easily translate to re-

sidential environments. One must consider unique psy-

chosocial and socio-cultural factors that influence smok-

ing in the home versus other settings. Moreover, children

of smokers may continue to be exposed to SHSe via

contaminated clothes, furniture, and other surfaces even

if parents enforce residential smoking restrictions [47].

Thus, an assumption that residential smoking restrictions

alone are sufficient to reduce child SHSe may lead to

public health programs that are overly simplistic and fail

to address other factors that influence child SHSe. This

shortcoming could be magnified in low-income and un-

derserved minority communities who face additional,

poverty-related barriers to smoking behavior change com-

pared to other populations. Therefore, research examin-

ing the associations between restrictions, maternal smo-

king, and child SHSe in the context of other smoking-

related factors within underserved, low-income popula-

tions is warranted.

The purpose of this study was to examine associations

among residential smoking restrictions, maternal smo-

king behavior, and child SHSe in the context of other

smoking-related factors in a population of low income,

AA maternal smokers. We hypothesized that residential

restrictions would relate to lower levels of reported child

SHSe and cotinine. Because we conceptualized residen-

tial smoking restrictions as predictive of broader mater-

nal smoking behavior change, we hypothesized that re-

strictions would relate to fewer maternal cigarettes smoked

per day and greater likelihood of intention to quit smo-

king.

2. METHODS

2.1. Design and Sample

This study focused on cross-sectional, pre-treatment

data collected as part of the ongoing clinical trial target-

ing African American, maternal smokers in medically

underserved neighborhoods of Philadelphia, Pennsyl-

vania. Recruitment occurred primarily through Women,

Infants, and Children (WIC) centers and pediatric pri-

mary care clinics as well as community newspaper, flier,

and mass transit advertisements between September

2004 and December 2008. Inclusion criteria required

that mothers smoked at least five cigarettes/day and ex-

posed their child to at least two cigarettes/day. Exclusion

criteria included psychiatric diagnoses, pregnancy, and

inability to speak English. All procedures were approved

by Temple University’s institutional review board.

2.2. Measures

Data were obtained from the eligibility screening and

a 75-minute, in-home baseline interview occurring ap-

proximately two weeks after screening. We selected va-

riables consistent with previous empirical literature and

the Behavioral Ecological Model [48] to capture a com-

prehensive explanation of contextual factors and level of

residential smoking restrictions on maternal smoking and

child SHSe. The assessment strategies used in the cur-

rent study have been reliable and valid in previous trials

with low income smokers [49].

2.2.1. Dependent Variables

Four dependent variables included reported child SHSe,

child cotinine, reported maternal cigarettes smoked/day,

and intention to quit smoking. Maternal cigarettes/day

was derived from summing the average number of ciga-

rettes mom smoked/day inside at home, outside at home,

away from home and in the car over the last two weeks.

Child SHSe was derived in the same manner across the

same smoking locations and by source. Intention to quit

in the next 30 days was measured as 1 = yes and 0 = no.

Child cotinine, an accurate and frequently used biomark-

er for SHSe [50], was obtained from urine samples col-

B. N. Collins et al. / HEALTH 2 (2010) 1264-1271

1266

lected using standardized procedures during in-home in-

terviews.

2.2.2. Independent and Controlling Variables

Residential smoking restriction was the hypothesized

primary predictor and was assessed using a four-point

response scale (1 = total indoor smoking ban to 4 = no

indoor restrictions). Restriction was dichotomized (0 =

no smoking restrictions, 1 = some to total smoking re-

strictions) for ease of interpretation and due to the dis-

tribution of responses showing that only 10% of partici-

pants reported a total smoking ban in their home [51].

Demographic, psychosocial, and smoking factors known

to influence maternal smoking were controlling variables.

2.2.2.1. Smoking Factors

Nicotine dependence was measured by the Fagerström

Test for Nicotine Dependence (FTND) [52]. Mothers

also reported whether their home had a convenient place

to smoke outdoors (1 = yes, 0 = no) and if there were

additional smokers living at home (0 = mother the only

smoker, 1 = additional smokers.) We collected total num-

ber of lifetime months mothers’ smoked daily and the

average hours/day that the child spends indoors.

2.2.2.2. Demographic Variables

Mothers’ education was coded as 0 = high school gra-

duate or less, 1 = education beyond high school, includ-

ing vocational training. Employment was coded as 0 =

unemployed, 1 = part- or full-time employment. House-

hold income was coded as 0 = less than $15,000 and 1 =

$15,000 or more. Maternal and child age were continu-

ous variables.

2.2.2.3. Psychosocial Variables

Maternal depressive symptoms were measured by the

Center for Epidemiologic Studies Depression Scale (CES-

D) [53]. General social support was measured using the

global score of the Interpersonal Support Evaluation List

[54]. Support for quitting smoking was assessed via a sin-

gle interview item (0 = none to 5 = very much). History

of current other substance abuse was obtained as 0 = no

and 1 = yes.

2.3. Statistical Analyses

Baseline data were double entered to verify accuracy.

Logical inspection of study variables for skewed distri-

butions and outliers were performed. Cotinine was log

transformed to the tenth power to normalize the skewed

distribution. Prior to conducting multiple regression and

logistic regression, bivariate associations between the

dichotomized home smoking restriction and criterion

variables were assessed to determine whether multivari-

ate analyses were appropriate. Additional bivariate asso-

ciations between criterion and controlling variables de-

termined which variables to include in multivariate ana-

lyses (< 0.10). Backwards stepwise method was used to

find the best model fit.

3. RESULTS

3.1. Participant Characteristics

Table 1 provides sample characteristics of 307 Afri-

can American maternal smokers in the study, reflecting a

predominantly single, light-to-moderate sample of ma-

ternal smokers living below poverty level.

Pearson correlations between dichotomized residential

smoking restriction and four criterion variables indicated

that restriction had a significant association with re-

ported child SHSe (r = –0.21, p < 0.001) and maternal

cigarettes/day smoked (r = –0.206, p < 0.001); but not

with cotinine (r = –0.10, p = 0.10) or intention to quit (r

= –0.01, p > 0.10). Because there was not a bivariate

association between restriction and either child cotinine

or maternal intention to quit smoking, we only conducted

multivariate analyses for reported child SHSe and mater-

nal cigarettes/day.

3.2. Multiple Regression Analyses

3.2.1. Reported Child SHSe from All Sources

The multiple regression model for reported child

SHSe was significant (F = 13.55, p < 0.001; R2 = 0.34),

but suggested that residential smoking restriction was

not associated with reported SHSe when controlling for

other factors. Three other factors predicted higher le-

vels of reported child SHSe: more maternal cigarettes

smoked/day, shorter daily smoking history, and addi-

tional smokers living at home. Not having a convenient

place to smoke outside and time spent indoors/day were

not significant covariates. (Table 2)

3.2.2. Total Maternal Cigarettes/Day Smoked

The multiple regression model for maternal cigarettes/

day was significant (F = 14.16, p < 0.001; R2 = 0.32) but

suggested that residential smoking restriction was not

associated with maternal smoking when controlling for

other factors. Significant covariates included greater nico-

tine dependence and older age. (Table 3)

4. DISCUSSION

This study examined hypothesized influence of resi-

dential smoking restrictions on child SHSe and maternal

smoking behaviors in a sample of underserved, African

B. N. Collins et al. / HEALTH 2 (2010) 1264-1271

1267

Table 1. Sample characteristics (n = 307).

Distributional Characteristics

Variable Mean SD Frequency

(n, %)

Child’s Age in Months* 18.9 14.9

Mother’s Age in Years 29.8 7.9

Home Smoking Restrictions

(raw)

- Total indoor restrictions

- Some area restrictions

- No indoor restrictions

28 (9.1%)

151 (49.2%)

128 (35.7%)

Home Restriction

(dichotomous)

- Some Restriction

- No Restriction

95 (30.9%)

212 (69.1%)

Martial Status

- Married/living with a

partner

- Single

56 (18.2%)

251 (81.8%)

Household Income

- $15,000 or below

- Above $15,000

208 (67.8%)

99 (32.2%)

Employed

- Unemployed

Education Greater than HS

degree

- Yes

- No

100 (32.6%)

207 (67.4%)

67 (21.8%)

240 (78.2%)

Mean # children in home 3.0 1.8

Number of smokers in child’s

home

- 1 smoker

- 2 or more smokers

144 (46.9%)

163 (53.1%)

Number of rooms in the home

- 0-5 rooms

- > 5 rooms

161 (44.8%)

198 (55.2%)

Nicotine Dependence (FTND) 4.7 1.8

Mean cigarettes/day smoked 11.7 6.2

Mean cigarettes /day child is

exposed 8.4 8.8

Child Urine Cotinine (ng/ml)

log10 1.23 0.52

Intention to quit in the next 30

days

- Yes

- No

88 (28.7%)

219 (71.3%)

Convenient place to smoke

outside

- Yes

- No

- Missing

342 (95.3%)

16 (4.5%)

1 (0.3%)

Support for Quitting Smoking

- None to Some

- A lot to Very Much

102 (33.2 %)

204 (66.8%)

History or Current Substance

Abuse

- Yes

- No

32 (10.4%)

275 (89.6%)

Depressive Symptoms

(CES-D) 18.9 10.4

General Social Support

(ISEL) 36.8 6.5

Negative Affect (PANAS) 16.8 7.6

*Dichotomously coded (0 = infants under 1 year; 1 = children of 1-4 years).

Table 2. Maternal report of cigarettes/day child is exposed re-

gressed on selected smoking, social, and demographic charac-

teristics*.

Standardized Coefficients

Model

Beta Std. ErrorP

Residential Restriction † –0.09 0.98 0.10

Cigarettes/day 0.52 0.08 < 0.001

More than 1 smoker at home0.10 0.88 0.04

Total months smoked –0.11 0.01 0.03

Education > high school –0.06 1.05 0.24

Avg Daily Time Baby

Indoors –0.05 0.09 0.33

Social Support –0.05 0.07 0.35

Substance Abuse –0.05 1.5 0.37

Child age 0.05 0.03 0.37

Nicotine dependence 0.04 0.28 0.44

Convenient Place to Smoke

Outside –0.04 2.0 0.48

*Dependent variable: Maternal-reported total baby exposure to cigarettes

from all sources; †Residential restriction coded as 1 = some to total smo-

king restrictions, 0 = no restrictions.

Table 3. Maternal cigarettes/day smoked regressed on selected

smoking, social, and demographic characteristics*.

Standardized Coefficients

Model

Beta Std. ErrorP

Residential Restriction† –0.072 0.747 0.187

Nicotine Dependence 0.526 0.188 0.000

child age –0.062 0.024 0.272

Education > high school –0.046 0.849 0.418

convenient place to smoke

outside –0.034 1.584 0.521

mother age 0.127 0.051 0.035

Income over 15,000 –0.072 0.797 0.210

substance abuse –0.086 1.119 0.126

*Dependent variable: average number of cigarettes smoked per day; †Re-

sidential restriction coded as 1 = some to total smoking restrictions, 0 = no

restrictions.

American maternal smokers. Restrictions related to re-

ported SHSe and maternal cigarettes/day in bivariate

analyses, but did not relate to cotinine or intention to

quit. Restrictions did not predict of either reported SHSe

or maternal cigarettes/day in their respective multivariate

models. Thus, our results suggest that residential smo-

king restrictions alone are not sufficient to reduce child

SHSe or to promote changes in maternal smoking in this

B. N. Collins et al. / HEALTH 2 (2010) 1264-1271

1268

population, and that additional policies or interventions

are needed to enhance such efforts to reduce child SHSe.

4.1. Child SHSe and Residential Smoking

Restriction

Our data suggest that residential smoking restrictions

may have the potential to influence reported smoking

behavior change and SHSe among AA maternal smokers

with preschool children (0-4 years old). However, when

accounting for broader contextual factors that also in-

fluence smoking and SHSe, our data suggest that resi-

dential smoking restrictions alone may not be sufficient

to affect children’s overall SHSe from all sources and in

all locations as captured by cotinine (a biomarker of

SHSe). More intensive strategies for reducing these child-

ren’s SHSe may be necessary. For example, our multi-

variate analyses showed that reported SHSe was influ-

enced by maternal cigarettes smoked/day, consistent with

previous research suggesting maternal smoking is the

most important predictor of child SHSe [1,33-35]. This

model also suggested that children have greater levels of

reported SHSe when there are more smokers living in

the home. Thus, even if families restrict smoking inside

the home, there appears to be the potential for children

to be exposed to other sources of SHSe. These sources

could include additional smokers living at home, or ter-

tiary levels of exposure (e.g., by contact with smokers’

clothes, hair, and surfaces within areas where smoking is

permitted [55]). Additional sources of SHSe in many

low-income families may also depend on the type of

housing conditions both inside and between smokers’

housing units, whether the parent is the head-of-house-

hold, and whether restrictions are favored by all smokers

living in the home—factors that could make enforce-

ment of smoking restrictions more difficult.

Future research should examine the influence of a to-

tal indoor smoking ban, something not possible with our

baseline dataset given the low proportion of mothers

reporting total bans. However, our results suggest that

other factors may need to be addressed in addition to

promoting smoking restrictions or bans. Further exami-

nation of barriers to smoke-free home enforcement could

help guide future intervention implementation. Experi-

ence with smoking restrictions in public venues suggests

that social norms influence enforcement of such policies.

Thus, developing interventions that build community

and family support for residential smoking restrictions

would capitalize on the influence of social norms that

oppose SHSe [56]. Local media could also play a role in

shaping social contingencies that promote smoke-free

homes [57]. Research that can prospectively examine

ways to shape anti-residential SHSe social norms will

inform future policy and individual-level interventions

for smoking behavior change.

4.2. Maternal Smoking and Residential

Smoking Restrictions

Our results did not support our hypothesis that resi-

dential restrictions would reduce smoking and increase

motivation to quit. With only 29% of our sample report-

ing intention to quit, this result could be a consequence

of accrual strategies in our clinical trial designed to in-

clude maternal smokers regardless of their present inter-

est in quitting smoking. Our results could also reflect our

sample of smoking mothers with young children—a po-

pulation that demonstrates greater challenges to quit-

ting smoking than the general population of smokers.

Perhaps future research could examine whether health

professionals, local policies, or family-level contingent-

cies that promote smoke-free homes could be catalysts

for smoking cessation in underserved communities [58-

63].

4.3. Limitations and Strengths

Our cross-sectional dataset limits the ability to infer

causal relations between residential smoking restrictions

and maternal smoking and child SHSe. Also, the pur-

posive sample of low income, AA maternal smokers may

limit generalizability of study results beyond similar

low-income populations. In this study, we did not ob-

serve the expected consistency between our self-reported

SHSe and cotinine data. Given that only 9% of partici-

pants in this study reported total smoking bans, we con-

clude that this data inconsistency is more likely to be

attributable to variability in restriction enforcement rather

than over-reporting of said restrictions. Moreover, pre-

vious clinical trials have demonstrated the reliability of

parent-reported smoking and child SHSe [64]. Future

studies should examine the relative influence of en-

forcement of residential smoking restrictions on child

SHSe, a hypothesis that could not be examined in the

current study. Despite these limitations, our study offers

future directions for research, intervention, and policy.

4.4. Significance

This study provides evidence that residential smoking

restrictions alone may not be sufficient to promote sig-

nificant reductions in child SHSe or change in maternal

daily smoking and intention to quit among maternal

smokers known to have increased tobacco-related mor-

bidity and mortality risk. Our results further suggests

that future programs may need to implement multi-level

interventions that promote improved advice about SHSe

[58,59] as well as in-home support that assists with the

B. N. Collins et al. / HEALTH 2 (2010) 1264-1271

1269

enforcement of smoking bans and promotes smoking ce-

ssation (something that these researchers are proposing

to examine).

Theory-based strategies can address sets of idio-graphic

factors that undermine smoking behavior change. They

also frame sets of factors that can guide the expansion of

family- and community-level norms supporting smok-

free homes and SHSe-reduction in low income, under-

served communities [65]. Globally, there are increasing

numbers of smoke-free policies to protect nonsmokers,

not only in workplaces and hospitality venues, but also

private spaces, such as cars (e.g., Maine [66]) and some

communities have instituted policies to prevent smoking

inside public housing, such as in Calabasas, CA [67].

However, it is important to consider that such policies

will be more effective if coupled by other interventions

that can assist families and smokers to achieve residen-

tial smoke-free goals. Future research should examine

how best to bridge community-supported residential SHSe

policy with improved access to smoking cessation inter-

vention. Communities planning smoke-free home inter-

ventions may need to blend resources and initiatives for

improving the quality and frequency of pediatric provi-

ders’ assessment and advice for smoking parents and

improving access to formal smoking intervention ser-

vices with their policy efforts in order to maximize the

likelihood of achieving intended SHSe reduction goals.

5. ACKNOWLEDGEMENT

This work was supported by the National Cancer Institute at the Na-

tional Institutes of Health to BC [K07 CA093756 and R01 CA105183].

REFERENCES

[1] U.S. Department of Health and Human Services (2006)

The Health Consequences of Involuntary Exposure to

Tobacco Smoke: A Report of the Surgeon General. At-

lanta, GA: U.S. Department of Health and Human Ser-

vices, Centers for Disease Control and Prevention, Coor-

dinating Center for Health Promotion, National Center

for Chronic Disease Prevention and Health Promotion,

Office on Smoking and Health.

[2] World Health Organization (2002) The World Health

Report: Reducing Risks, Promoting Healthy Life, Septem-

ber 2010. http://www.who.int/whr/2002/en/whr02_en.pdf

[3] Carmichael, S.L. and Ahluwalia, I.B. (2000) Correlates

of postpartum smoking relapse. Results from the preg-

nancy risk assessment monitoring system (PRAMS).

American Journal of Preventive Medicine, 19(3), 193-196.

[4] California-Environmental Protection Agency. (1997) Health

effects of exposure to environmental tobacco smoke. Final

draft for scientific, public, and SRP review, California En-

vironmental Protection Agency, Office of Environmental

Health Hazard Assessment.

[5] Gergen, P.J., Fowler, J.A., Maurer, K.R., Davis, W.W. and

Overpeck, M.D. (1998) The burden of environ- mental to-

bacco smoke exposure on the respiratory health of children

2 months through 5 years of age in the United States: Third

national health and nutrition examination survey, 1988 to

1994. Pediatrics, 101(2 ), E8.

[6] Cobanoglu, N., Kiper, N., Dilber, E., Gurcan, N., Goc- men,

A., Ozcelik, U., et al. (2007) Environmental tobacco smoke

exposure and respiratory morbidity in children. Inhalation

and Toxicology, 19(9), 779-785.

[7] Collins, B.N., Wileyto, E.P., Murphy, M.F. and Munafo,

M.R. (2007) Adolescent environmental tobacco smoke ex-

posure predicts academic achievement test failure. Journal

of Adolescent Health, 41(4), 363-370.

[8] Eskenazi, B. and Castorina, R. (1999) Association of pre-

natal maternal or postnatal child environmental tobacco

smoke exposure and neurodevelopmental and behavioral

problems in children. Environmental Health Perspectives,

107(12), 991-1000.

[9] Johansson, A., Ludvigsson, J. and Hermansson, G. (2008)

Adverse health effects related to tobacco smoke exposure

in a cohort of three-year olds. Acta Paediatrica, 97(3),

354-357.

[10] Lannero, E., Wickman, M., van Hage, M., Bergstrom, A.,

Pershagen, G. and Nordvall, L. (2008) Exposure to envi-

ronmental tobacco smoke and sensitisation in children.

Thorax, 63(2), 172-176.

[11] Shenkin, J.D., Broffitt, B., Levy, S.M. and Warren, J.J.

(2004) The association between environmental tobacco

smoke and primary tooth caries. Journal of Public Health

and Dentistry, 64(3), 184-186.

[12] Sundell, H.W. (2004) SIDS prevention-good progress,

but now we need to focus on avoiding nicotine. Acta

Paediatrica, 93(4), 450-452.

[13] Weitzman, M., Byrd, R.S., Aligne, C.A. and Moss, M.

(2002) The effects of tobacco exposure on children’s be-

havioral and cognitive functioning: Implications for cli-

nical and public health policy and future research. Neu-

rotoxicology and Teratology, 24(3), 397-406.

[14] Hill, S.C. and Liang, L. (2008) Smoking in the home and

children’s health. Tobacco Control, 17(1), 32-37.

[15] Kegler, M.C. and Malcoe, L.H. (2002) Smoking restric-

tions in the home and car among rural Native American

and white families with young children. Preventive Medi-

cine, 35(4), 334-342.

[16] Gonzales, M., Malcoe, L.H., Kegler, M.C. and Espinoza,

J. (2006) Prevalence and predictors of home and auto-

mobile smoking bans and child environmental tobacco

smoke exposure: a cross-sectional study of U.S.- and Me-

xico-born Hispanic women with young children. BMC

Public Health, 6, 265.

[17] Hopper, J.A. and Craig, K.A. (2000) Environmental to-

bacco smoke exposure among urban children. Pediat-

rics, 106(4), E47.

[18] Castro, M., Schechtman, K.B., Halstead, J. and Bloom-

berg, G. (2001) Risk factors for asthma morbidity and

mortality in a large metropolitan city. Journal of Asthma,

38(8), 625-635.

[19] Claudio, L., Tulton, L., Doucette, J. and Landrigan, P.J.

(1999) Socioeconomic factors and asthma hospitalization

rates in New York City. Journal of Asthma, 36(4), 343-

350.

[20] Crain, E.F., Weiss, K.B., Bijur, P.E., Hersh, M., West-

B. N. Collins et al. / HEALTH 2 (2010) 1264-1271

1270

brook, L. and Stein, R.E. (1994) An estimate of the

prevalence of asthma and wheezing among inner-city

children. Pediatrics, 94(3), 356-362.

[21] Perera, F.P., Illman, S.M., Kinney, P.L., Whyatt, R.M.,

Kelvin, E.A., Shepard, P., et al. (2002) The challenge of

preventing environmentally related disease in young

children: Community-based research in New York City.

Environmental Health Perspectives, 110(2), 197-204.

[22] Tanne, J.H. (2001) Asthma “crisis” for black Americans.

British Medical Journal, 323(7308), 302.

[23] Ahijevych, K. and Garrett, B.E. (2004) Menthol phar-

macology and its potential impact on cigarette smoking

behavior. Nicotine and Tobacco Research, 6(Suppl 1),

S17-28.

[24] Benowitz, N.L., Perez-Stable, E.J., Fong, I., Modin, G.,

Herrera, B. and Jacob, P. (1999) Ethnic differences in

N-glucuronidation of nicotine and cotinine. Journal of

Pharmacology and Experimental Therapeutics, 291(3),

1196-1203.

[25] U.S. Department of Health and Human Services. (1998)

Tobacco Use among U.S. Racial/Ethnic Minority Groups-

African Americans, American Indians and Alaska Na-

tives, Asian Americans and Pacific Islanders, and His-

panics: A Report of the Surgeon General. Atlanta, Geor-

gia: U.S. Department of Health and Human Services,

Centers for Disease Control and Prevention, National

Center for Chronic Disease Prevention and Health Pro-

motion, Office on Smoking and Health.

[26] Mannino, D.M., Moorman, J.E., Kingsley, B., Rose, D.

and Repace, J. (2001) Health effects related to environ-

mental tobacco smoke exposure in children in the United

States: data from the Third National Health and Nutrition

Examination Survey. Archives of Pediatric and Adoles-

cent Medicine, 155(1), 36-41.

[27] Tang, D., Warburton, D., Tannenbaum, S.R., Skipper, P.,

Santella, R.M., Cereijido, G.S., et al. (1999) Molecular

and genetic damage from environmental tobacco smoke

in young children. Cancer Epidemiology Biomarkers and

Prevention, 8(5), 427-431.

[28] Wilson, S.E., Kahn, R.S., Khoury, J. and Lanphear, B.P.

(2005) Racial differences in exposure to environmental

tobacco smoke among children. Environmental Health

Perspectives, 113(3), 362-367.

[29] Fiore, M.C, Jaen, C.R., Baker, T.B., Baker, C.R., Bailey,

W.C., Benowitz, N.L., et al. (2008) Treating tobacco use

and dependence: 2008 update. September 2010.

http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=hsa

hcpr&part=A28163

[30] Bartecchi, C., Alsever, R.N., Nevin-Woods, C., Thomas,

W.M., Estacio, R.O., Bartelson, B.B., et al. (2006) Re-

duction in the incidence of acute myocardial infarction

associated with a citywide smoking ordinance. Circula-

tion, 114(14), 1490-1496.

[31] Sargent, R.P., Shepard, R.M. and Glantz, S.A. (2004)

Reduced incidence of admissions for myocardial infarct-

tion associated with public smoking ban: Before and af-

ter study. British Medical Journal, 328(7446), 977-980.

[32] Americans for Nonsmokers’ Rights Foundation (2009)

Smokefree lists, maps, and data. September, 2010.

http://www.no-smoke.org/goingsmokefree.php

[33] Ashley, M.J. and Ferrence, R. (1998) Reducing children’s

exposure to environmental tobacco smoke in homes: Is-

sues and strategies. Tobacco Control, 7(1), 61-65.

[34] Mannino, D.M., Siegel, M., Husten, C., Rose, D. and

Etzel, R. (1996) Environmental tobacco smoke exposure

and health effects in children: results from the 1991 Na-

tional Health Interview Survey. Tobacco Control, 5(1),

13-18.

[35] Dwyer, T., Ponsonby, A.L. and Couper, D. (1999) To-

bacco smoke exposure at one month of age and subse-

quent risk of SIDS - A prospective study. American Jour-

nal of Epidemiology, 149(7), 593-602.

[36] McMillen, R.C., Winickoff, J.P., Klein, J.D. and Weitz-

man, M. (2003) US adult attitudes and practices regard-

ing smoking restrictions and child exposure to environ-

mental tobacco smoke: Changes in the social climate

from 2000-2001. Pediatrics, 112(1 Pt 1), e55-60.

[37] World Health Organization (2009) IARC Handbooks of

Cancer Prevention. Tobacco Control. Lyon, France, World

Health Organization.

[38] United States Census Bureau (2008) Population Estimates.

http://www.census.gov/popest/estimates.html

[39] Jochelson, T., Hua, M. and Rissel, C. (2003) Knowledge,

attitudes and behaviours of caregivers regarding chil-

dren’s exposure to environmental tobacco smoke among

Arabic and Vietnamese-speaking communities in Sydney,

Australia. Ethnicity and Health, 8(4), 339-351.

[40] Carlson, L.E., Goodey, E., Bennett, M.H., Taenzer, P. and

Koopmans, J. (2002) The addition of social support to a

community-based large-group behavioral smoking cessa-

tion intervention: improved cessation rates and gender

differences. Addictive Behaviors, 27(4), 547-559.

[41] Collins, B.N., Wileyto, E., Patterson, F., Rukstalis, M.,

Audrain-McGovern, J., Kaufmann, V., et al. (2004) Gen-

der differences in smoking cessation in a placebo-con-

trolled trial of bupropion with behavioral counseling.

Nicotine and Tobacco Research, 6(1), 27-37.

[42] Perkins, K.A., Donny, E. and Caggiula, A.R. (1999) Sex

differences in nicotine effects and self-administration:

review of human and animal evidence. Nicotine and To-

bacco Research, 1(4), 301-315.

[43] Royce, J.M., Corbett, K., Sorensen, G. and Ockene, J.

(1997) Gender, social pressure, and smoking cessations:

the Community Intervention Trial for Smoking Cessation

(COMMIT) at baseline. Social Science and Medicine,

44(3), 359-370.

[44] Scharf, D. and Shiffman, S. (2004) Are there gender dif-

ferences in smoking cessation, with and without bu-

propion? Pooled- and meta-analyses of clinical trials of

Bupropion SR. Addiction, 99(11), 1462-1469.

[45] Swan, G.E., Jack, L.M. and Ward, M.M. (1997) Sub-

groups of smokers with different success rates after use

of transdermal nicotine. Addiction, 92(2), 207-217.

[46] Wetter, D.W., Fiore, M.C., Young, T.B., McClure, J.B.,

de Moor, C.A. and Baker, T.B. (1999) Gender differences

in response to nicotine replacement therapy: Objective

and subjective indexes of tobacco withdrawal. Experimen-

tal and Clinical Psychopharmacology, 7(2), 135-144.

[47] Matt, G.E., Bernert, J.T. and Hovell, M.F. (2008) Meas-

uring secondhand smoke exposure in children: An eco-

logical measurement approach. Journal of Pediatric Psy-

chology, 33(2), 156-175.

[48] Hovell, M.F., Wahlgren, D.R. and Adams, M.A. (2009)

The logical and empirical basis for the behavioral eco-

B. N. Collins et al. / HEALTH 2 (2010) 1264-1271

1271

logical model. In: DiClemente, R.J., Crosby, R. and Ke-

gler, M. Eds., Emerging Theories and Models in Health

Promotion Research and Practice, 2nd Edition, Jossey-

Bass Inc., San Francisco.

[49] Matt, G.E., Hovell, M.F., Zakarian, J.M., Bernert, J.T.,

Pirkle, J.L. and Hammond, S.K. (2000) Measuring sec-

ondhand smoke exposure in babies: The reliability and

validity of mother reports in a sample of low-income

families. Health Psychology, 19(3), 232-241.

[50] Benowitz, N.L. (1996) Cotinine as a biomarker of envi-

ronmental tobacco smoke exposure. Epidemiological Re-

view, 18(2), 188-204.

[51] Clark, P.I., Schooley, M.W., Pierce, B., Schulman, J.,

Hartman, A.M. and Schmitt, C.L. (2006) Impact of home

smoking rules on smoking patterns among adolescents

and young adults. Preventing Chronic Diseases, 3(2), A41.

[52] Pomerleau, C.S., Carton, S.M., Lutzke, M.L., Flessland,

K.A. and Pomerleau, O.F. (1994) Reliability of the Fa-

gerstrom Tolerance Questionnaire and the Fagerstrom

Test for Nicotine Dependence. Addictive Behaviors, 19(1),

33-39.

[53] Radloff, L. (1977) A CES-D scale: A self-report depress-

sion scale for research in the general population. Applied

Psychology Measurement, 1385-1401.

[54] Brookings, J.B. and Bolton, B. (1988) Confirmatory fac-

tor analysis of the Interpersonal Support Evaluation List.

American Journal of Community Psychology, 16(1), 137-

147.

[55] Matt, G.E., Quintana, P.J., Hovell, M.F., Bernert, J.T.,

Song, S., Novianti, N., et al. (2004) Households con-

taminated by environmental tobacco smoke: Sources of

infant exposures. Tobacco Control, 13(1), 29-37.

[56] Schuster, M.A., Franke, T. and Pham, C.B. (2002) Smok-

ing patterns of household members and visitors in homes

with children in the United States. Archives of Pediatric

and Adolescent Medicine, 156(11), 1094-1100.

[57] Evans, W.D., Crankshaw, E., Nimsch, C., Morgan-Lopez,

A., Farrelly, M.C. and Allen, J. (2006) Media and sec-

ondhand smoke exposure: Results from a national survey.

American Journal of Health Behaviors, 30(1), 62-71.

[58] Collins, B.N., Levin, K.P. and Bryant-Stephens, T. (2007)

Pediatricians’ practices and attitudes about environmental

tobacco smoke and parental smoking. Journal of Pediat-

rics, 150(5), 547-552.

[59] Mueller, D. and Collins, B.N. (2008) Pediatric otolayn-

gologists’ actions regarding secondhand smoke exposure:

Pilot data suggest an opportunity to enhance tobacco in-

tervention. Journal of Otolaryncology-Head and Neck

Surgery, 139(3), 348-352.

[60] Horwitz, M.B., Hindi-Alexander, M. and Wagner, T.J.

(1985) Psychosocial mediators of abstinence, relapse,

and continued smoking: A one-year follow-up of a mini-

mal intervention. Addictive Behaviors, 10(1), 29-39.

[61] Gilpin, E.A., White, M.M., Farkas, A.J. and Pierce, J.P.

(1999) Home smoking restrictions: Which smokers have

them and how they are associated with smoking behavior.

Nicotine and Tobacco Research, 1(2), 153-162.

[62] Pizacani, B.A., Martin, D.P., Stark, M.J., Koepsell, T.D.,

Thompson, B. and Diehr, P. (2004) A prospective study

of household smoking bans and subsequent cessation re-

lated behavior: The role of stage of change. Tobacco Con-

trol, 13(1), 23-28.

[63] Shopland, D.R., Anderson, C.M. and Burns, D.M. (2006)

Association between home smoking restrictions and

changes in smoking behavior among employed women.

Journal of Epidemiology and Community Health, 60

(Suppl 2), 44-50.

[64] Matt, G.E., Wahlgren, D.R., Hovell, M.F., Zakarian, J.M.,

Bernert, J.T., Meltzer, S.B., et al. (1999) Measuring en-

vironmental tobacco smoke exposure in infants and young

children through urine cotinine and memory-based pa-

rental reports: Empirical findings and discussion. To-

bacco Control, 8(3 ), 282-289.

[65] Hovell, M.F., Wahlgren, D.R. and Gehrman, C.A. (2002)

The behavioral ecological model: Integrating public health

and behavioral science. Jossey-Bass, San Francisco.

[66] Haskell, M. (2008) Law prohibiting smoking in cars gets

Baldacci OK. Bangor Daily News, Bangor.

[67] Associated Press (2008) New smoking restriction ignites

debate: Ban on lighting up with a child in car is part of

trend to violate rights, foes say. The Sacramento Bee, 7

January 2008.