Vol.2, No.11, 1264-1271 (2010)
Copyright © 2010 SciRes. Openly accessible at http://www.scirp.org/journal/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.
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
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
Copyright © 2010 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
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-
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
Copyright © 2010 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
lected using standardized procedures during in-home in-
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. 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. 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. 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.
3.1. 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)
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
Copyright © 2010 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
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
- Total indoor restrictions
- Some area restrictions
- No indoor restrictions
28 (9.1%)
151 (49.2%)
128 (35.7%)
Home Restriction
- Some Restriction
- No Restriction
95 (30.9%)
212 (69.1%)
Martial Status
- Married/living with a
- Single
56 (18.2%)
251 (81.8%)
Household Income
- $15,000 or below
- Above $15,000
208 (67.8%)
99 (32.2%)
- Unemployed
Education Greater than HS
- 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
- 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
- Yes
- No
88 (28.7%)
219 (71.3%)
Convenient place to smoke
- 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
- 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-
Standardized Coefficients
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
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
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
Copyright © 2010 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
population, and that additional policies or interventions
are needed to enhance such efforts to reduce child SHSe.
4.1. Child SHSe and Residential Smoking
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-
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
Copyright © 2010 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
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.
This work was supported by the National Cancer Institute at the Na-
tional Institutes of Health to BC [K07 CA093756 and R01 CA105183].
[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),
[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-
[20] Crain, E.F., Weiss, K.B., Bijur, P.E., Hersh, M., West-
B. N. Collins et al. / HEALTH 2 (2010) 1264-1271
Copyright © 2010 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
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),
[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),
[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.
[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.
[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),
[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.
[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
Copyright © 2010 SciRes. http://www.scirp.org/journal/HEALTH/Openly accessible at
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),
[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-
[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.