Screening for children's exposure to environmental tobacco smoke in a pediatric primary care setting
Article Outline
Groner JA, Hoshaw-Woodard S, Koren G, Klein J, Castile R. Arch Pediatr Adolesc Med 2005;159:450-5
Context The American Academy of Pediatrics has recommended that pediatricians assess their patients’ environmental tobacco smoke (ETS) exposure, but the specific questions most likely to identify children with high ETS exposure are not known. Cotinine, a nicotine metabolite present in hair, can be used to quantify months of ETS exposure.
Objective To develop a brief screening tool that will accurately predict ETS exposure as defined by a child's hair cotinine level.
Setting Columbus Children's Hospital Primary Care Center.
Participants A convenience sample of healthy children age 2 weeks to 3 years of both self-reported smokers and nonsmokers.
Interventions Screening questions regarding home ETS exposure.
Main Outcome Measure Performance of the screening questions compared with child hair cotinine levels.
Results Hair samples and questionnaire data were obtained from 291 children. Based on clinical applicability and statistical significance, 3 questions (“Does the mother smoke?,” “Do others smoke?,” and “Do others smoke inside?”) were selected as a valid screening tool to determine children's ETS exposure risk. Maternal reports of smoking outside only or smoking only a few cigarettes per day had no impact on child hair cotinine levels.
Conclusions It was possible to derive a simple, specific, and valid screening tool that can be used in pediatric offices to identify children at risk for ETS exposure. Further research is needed to test this tool prospectively.
Comment Secondhand tobacco smoke exposure of children, and its associated morbidity and mortality, is completely preventable. Although the pediatric community is beginning to recognize its role in counseling families on this issue, many pediatricians remain reluctant to discuss tobacco use and secondhand smoke exposure.1, 2 Two of the barriers cited are the lack of a simple, validated screening tool and the clinician's lack of training in brief, effective smoking cessation counseling techniques.3 The study of Groner et al, which uses hair cotinine levels to validate a set of screening questions, removes the first barrier. The next step is training pediatricians in brief, effective counseling skills and the use of community smoking cessation resources. All tobacco users should be advised to quit and to make their homes and cars smoke-free. Pediatricians can deliver this message and either provide counseling themselves or provide a referral to an appropriate cessation service (such as the national quit line, 1-800-QUIT-NOW).
There are limitations to using these screening questions in the research setting, however. Complete understanding of the metabolism of nicotine to cotinine has not been achieved, particularly in children and minority groups. There are indications that children metabolize many drugs differently than adults;4 similarly, there are several studies that have suggested the existence of “slow metabolizers” of nicotine and that these persons are more likely to be members of some minority groups.5 Groner et al's data from African-American subjects supports this finding. Our poor understanding of these differences makes the use of these screening questions to quantify exposure a challenge. Regardless, the screening questions developed by Groner and her team are entirely appropriate in the clinical setting and provide a much-needed tool.
References
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- Racial and ethnic differences in serum cotinine levels of cigarette smokers: Third National Health and Nutrition Examination Survey, 1988-1991. JAMA. 1998;280:135–139
PII: S0022-3476(05)00810-3
doi:10.1016/j.jpeds.2005.08.067
© 2005 Elsevier Inc. All rights reserved.
