PEDIATRICS Volume 141, number S1, January 2018:e20171026Supplement Article

Tobacco Control Laws and Pediatric AsthmaJonathan Hatoun, MD, MPH, MS, a Kendra Davis-Plourde, MA, b Brian Penti, MD, c Howard Cabral, PhD, b Lewis Kazis, ScDb

aDivision of General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts; bSchool of Public Health, Boston University, Boston, Massachusetts; and cDepartment of Family Medicine, Boston Medical Center, Boston, Massachusetts

Dr Hatoun conceptualized and designed the study and drafted the initial manuscript; Ms Davis-Plourde conducted the initial analyses and reviewed and revised the manuscript; Drs Penti, Cabral, and Kazis conceptualized and designed the study and critically reviewed the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

DOI: https:// doi. org/ 10. 1542/ peds. 2017- 1026P

Accepted for publication Sep 6, 2017

Address correspondence to Jonathan Hatoun, MD, MPH, MS, Pediatric Physicians’ Organization at Children’s, Division of General Pediatrics, Boston Children’s Hospital, 77 Pond Ave, Suite 205C, Brookline, MA 02445. E-mail: jonathan.hatoun@childrens.harvard.edu

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2018 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

FUNDING: No external funding.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

BACKGROUND: Exposure to environmental tobacco smoke increases pediatric asthma severity. Strict, state-level tobacco control reduces smoking. The Child Asthma Call-Back Survey (Child ACBS) is a nationally representative survey of the guardians of children with asthma. The American Lung Association’s annual State of Tobacco Control report grades tobacco control laws in each state including a tax grade (cigarette excise tax relative to the national mean), and a smoke-free air grade (number of locations where smoking is prohibited).METHODS: We joined Child ACBS data from 2006 to 2010 with corresponding state and year tobacco grades. In the primary analysis, we investigated the effect of state tax grades on a child’s asthma severity by using a logistic regression model adjusting for year. A secondary analysis assessed the impact of smoke-free air grades on in-home smoking.RESULTS: Our analysis included 12 860 Child ACBS interviews from 35 states over 5 years, representing over 24 million individuals. We merged 112 unique State of Tobacco Control grades with patient data by state and year. A higher tax grade was associated with reduced severity (adjusted odds ratio = 1.40; P = .007, 95% confidence interval: 1.10–1.80). A better smoke-free air grade was not associated with decreased in-home smoking after adjusting for confounding by income and type of residence.CONCLUSIONS: A stronger tobacco tax is associated with reduced asthma severity. Further study is needed to determine the effect of smoke-free air laws on in-home environmental. This work supports ongoing efforts to strengthen tobacco control through federal and state regulations.

abstract

by guest on April 23, 2021www.aappublications.org/newsDownloaded from

PEDIATRICS Volume 141, number S1, January 2018 S131

Asthma is a widely prevalent and expensive chronic pediatric condition that can be controlled with trigger mitigation and medication.1 – 4 A common trigger for patients with asthma is cigarette smoke, an environmental pollutant that children continue to be exposed to frequently and that they often have no choice but to inhale because of its presence in their homes.5 – 8 Reducing environmental tobacco smoke exposure (TSE) can reduce the number of asthma exacerbations children experience.9 – 12

Efforts to reduce smoking and environmental TSE have been ongoing for decades, yet rates of tobacco exposure are still alarmingly high, with more than half of children with asthma aged 6 to 19 years exposed to environmental tobacco smoke from 2003 to 2010.13, 14 Sadly, efforts aimed at changing parental behavior to reduce children’s environmental TSE have not demonstrated clear effectiveness.15 However, evidence suggests that state and federal policy, such as larger tobacco excise taxes can affect smoking rates.7, 14

The primary goal of this study is to examine whether a stronger cigarette excise tax is associated with improved pediatric asthma severity. We hypothesized that states with higher tobacco excise taxes would have fewer patients with severe persistent asthma. To test this hypothesis, we combined data from the Child Asthma Call-Back Survey (Child ACBS) and the American Lung Association’s annual State of Tobacco Control (SoTC) report. The Child ACBS is a follow-up survey to the nationally representative Behavioral Risk Factor Surveillance System, an ongoing, state-by-state survey of adults with a focus on health-related risk behaviors, chronic health conditions, and the use of preventive services. The Child ACBS targets only those adults who acknowledged caring for a child with

asthma and uses nationally weighted representative sampling. Questions in the callback survey focus on the home environment, trigger exposures, symptom frequency, medication use, and interference with daily activity.

The American Lung Association’s annual SoTC report has information on state-level policies as they relate to tobacco control. The SoTC report assigns a letter grade (A through F) to each state for both the amount of their cigarette excise tax and type of local smoke-free air laws. The tobacco tax grade is determined by comparing each state’s cigarette excise tax dollar amount to the national mean that year. This methodology allows the grading scale to be dynamic as new laws are passed each year, such that an unchanged excise tax value could receive a lower grade from 1 year to the next, if the national mean were to increase. The smoke-free air grade is derived from the number of areas in which smoking is prohibited that year and how well those regulations are enforced. It is based on criteria developed by an advisory committee convened by the National Cancer Institute.16

METhODS

All data sets used in this study are publicly available and deidentified. We merged patient-level data (Child ACBS) with state-level data (tax grade and smoke-free air grade from the SoTC reports) for the years of 2006 through 2010. A change in the survey methodology of the Child ACBS in 2011 rendered comparisons to previous years invalid, therefore limiting the continuous period of analysis to the years selected. Each patient survey was matched to the corresponding state and year of tobacco tax and smoke-free air grades. Asthma severity was calculated for each patient as either intermittent, mild persistent, moderate persistent, or severe

persistent by using the patient-level survey data. Child ACBS responses related to number of days with symptoms, nighttime awakenings, short-acting β-agonist use, and interference with daily activity were used to determine a patient’s severity in accordance with the National Heart Blood and Lung Institute’s guidelines for the classification of asthma severity by age.17

In the primary analysis, we investigated the effect of the state tax grade on a child’s asthma severity by using logistic regression models. Tax grades A, B, and C were considered high grades, whereas D and F were considered low. Severity levels were dichotomized into severe persistent asthma and all other categorizations of severity, which were less severe (moderate persistent, mild persistent, and intermittent). Because of a secular trend toward reduced smoking across the country during the years of this study, regression models were adjusted for year.

In a secondary analysis on the merged data set, we explored the effect of smoke-free air grade on guardian-reported smoking in the home by using logistic regression models. Guardian-reported smoking in the home was dichotomized into any smoking reported in the home or no smoking reported in the home.

All statistical analyses were performed by using SAS version 9.4 (SAS Institute, Inc., Cary, NC) and accounted for strata, cluster, and individual weighting variables provided in the Child ACBS. Variables available to test for confounding were income, education, employment status, residence type, insurance status, medical cost barriers, age, sex, and race. The Boston Medical Center Institutional Review Board deemed the protocol exempt.

RESULTS

Our analysis data set included 12 860 Child ACBS interviews conducted in 35 different states at

by guest on April 23, 2021www.aappublications.org/newsDownloaded from

HATOuN et alS132

various intervals over the 5-year period. Because different states conduct the Child ACBS at differing intervals on the basis of funding, the representation of each region of the country in the data set varied slightly from year to year (Table 1). On the basis of the nationally weighted representative sampling, these interviews are generalizable to over 24 million individuals. The demographics of the population studied can be found in Table 2. There were 112 unique state-year combinations in the survey data, and each survey conducted in that state and year was matched to the corresponding SoTC tax and smoke-free air grades in the data set. State-level data for tax grade and smoke-free air grade by year can be seen in Table 3.

In the population surveyed, 50% were considered to have persistent asthma by symptom report. Twelve percent of the sample were classified as having the primary outcome of severe persistent asthma, with the rest of the patients classified as moderate persistent, mild persistent, or intermittent. The secondary outcome of smoking in the home demonstrated a secular trend during toward reduced in-home smoke during the time period of data analyzed (Table 3).

A stronger tax grade was associated with reduced asthma severity when adjusting for year (adjusted odds ratio [aOR] = 1.40; P = .007, 95% confidence interval [CI]: 1.10–1.08). After testing for possible confounding by income, employment, other measures of financial difficulty,

education, sex, race, insurance status, and residence type, none of the variables were confounders of the association between tax grade and asthma severity.

A better smoke-free air grade was associated with less reported in-home smoking adjusting only for year (aOR = 1.38, P = .022, 95% CI: 1.05–1.82). However, income and residence type (private versus public) were found to confound the association between air grade and smoking in the home. After adjusting for these variables, the strength of the association was not statistically significant (aOR = 1.20, P = .23, 95% CI: 0.89–1.60).

DISCUSSION

This study demonstrates the impact of tobacco control policies on the well-being of children with asthma. Although it is known that statewide legislation on the price of cigarettes can influence smoking

rates, this study demonstrates that policy changes are associated with symptom improvements at the level of the pediatric patient with asthma. In states with higher cigarette excise taxes, we found significantly reduced reports of symptoms consistent with severe persistent asthma. These findings are in keeping with a study by Ma18 in which an interrupted time series design revealed a dampening in the increasing trend for asthma-related hospitalizations in Pennsylvania after enactment of a law to increase the cigarette excise tax.

In states with more restrictions on public smoking, we found reduced reports of smoking in the home, a known trigger for asthma; however, this relationship was confounded by income and type of residence and not statistically significant after adjustment for these variables. Clean air laws have been shown to decrease rates of asthma hospitalization and emergency department visits among children with asthma.19 – 22

TABLE 1 Distribution of Survey Data by Region and Year (N = 12 860)

2006 2007 2008 2009 2010

n (%) n (%) n (%) n (%) n (%)

Northeast 618 (28.00) 676 (22.35) 846 (32.60) 752 (27.51) 461 (20.04)South 402 (18.21) 743 (24.57) 491 (18.92) 494 (18.07) 568 (24.70)Midwest 710 (32.17) 885 (29.27) 904 (34.84) 825 (30.18) 520 (22.61)West 477 (21.61) 720 (23.81) 354 (13.64) 663 (24.25) 751 (32.65)Total 2207 3024 2595 2734 2300

Reported percent values are weighted.

TABLE 2 Demographics of the Representative Population of Children Surveyed (N = 24 372 086)

n (%)

Male 14 394 252 (59.06)Age group, y 0–<5 3 945 851 (16.19) 5–<10 7 433 021 (30.50) 10–<15 7 534 197 (30.91) 15–17 5 458 425 (22.40)Race White, non-Hispanic 8 850 219 (36.31) Other than white or Hispanic 7 669 251 (31.47) Any race and ethnicity 7 852 616 (32.22)Insurance Private 15 194 452 (62.91) Public 6 306 946 (26.11) Other 1 661 235 (6.88) No insurance 990 568 (4.10)

Reported percent values are weighted.

by guest on April 23, 2021www.aappublications.org/newsDownloaded from

PEDIATRICS Volume 141, number S1, January 2018 S133

Additionally, recent evidence suggests worsening air quality in California is associated with worsening parent reports of pediatric respiratory symptoms.23

This study leverages nationally representative survey information from many states over 5 years to emphasize the need for legislative efforts aimed at restricting tobacco use to improve population health. However, excise taxes and smoke-free air laws may not be the only policy tools by which to limit smoking. Funding for tobacco prevention and cessation programs as well as efforts to restrict youth access to tobacco are other tools that were tracked by the SoTC reports. Unfortunately, changes in the report methodology over time limit the ability to use these findings in a similar manner to the excise tax and smoke-free air grades. Other untracked political efforts to limit environmental TSE to children with asthma might have occurred during the study, which would increase the chances that we have falsely rejected the null hypothesis.

Other limitations of this study include the inability to account for regional and seasonal variation factors that contribute to asthma, such as pollen, pollution, pests, cold weather, or outbreaks of viral respiratory illnesses. Still, given the large sample size in each state with sampling throughout the year in all states, these unmeasured factors are unlikely to account for the differences seen between states and years. Additionally, some states only contributed intermittent Child ACBS data because of state-level budget decisions. Although this limits the ability to detect continuous change by state, our controlling for time mitigates some of the impact of intermittent data on this study.

The methodology used here can be a powerful way to assess policy change. Linking statewide legal changes to patient-level outcomes TA

BLE

3 St

ate-

and

Sur

vey-

Leve

l Fin

ding

s Fr

om th

e Co

mbi

ned

Data

Set

2006

2007

2008

2009

2010

Tota

l

Stat

e le

vel

N =

23N

= 31

N =

22N

= 21

N =

18N

= 11

2

Tax

grad

e, n

(%

)

Hi

gh14

(60

.87)

17 (

54.8

4)14

(63

.64)

13 (

61.9

0)11

(61

.11)

69 (

60.0

0)

Lo

w9

(39.

13)

14 (

45.1

6)8

(36.

36)

8 (3

8.10

)7

(38.

89)

46 (

40.0

0)

Smok

e-fr

ee g

rade

, n (

%)

High

12 (

54.5

5)19

(61

.29)

14 (

66.6

7)17

(85

.00)

14 (

77.7

8)76

(67

.86)

Low

10 (

45.4

5)12

(38

.71)

7 (3

3.33

)3

(15.

00)

4 (2

2.22

)36

(32

.14)

Surv

ey le

vel

N =

5 107

240

N =

6 741

340

N =

4 592

632

N =

4 766

749

N =

3 164

126

N =

24 37

2 086

Se

veri

ty, n

(%

)

In

term

itten

t2 3

18 71

0 (4

5.40

)3 5

43 13

4 (5

2.56

)2 3

07 76

8 (5

0.25

)2 4

26 35

5 (5

0.90

)1 5

98 26

5 (5

0.51

)12

194 2

32 (

50.0

3)

M

ild1 2

79 58

6 (2

5.05

)1 5

87 84

2 (2

3.55

)1 2

39 26

9 (2

6.98

)1 2

99 38

2 (2

7.26

)89

8 248

(28

.39)

6 304

327

(25.

87)

Mod

erat

e72

0 884

(14

.11)

862 7

23 (

12.8

0)54

6 070

(11

.89)

511 3

54 (

10.7

3)33

4 400

(10

.57)

2 975

431

(12.

21)

Seve

re78

8 060

(15

.43)

747 6

41 (

11.0

9)49

9 524

(10

.88)

529 6

57 (

11.1

1)33

3 213

(10

.53)

2 898

096

(11.

89)

Sm

oke

in h

ome,

n (

%)

Yes

628 0

09 (

12.4

6)71

1 370

(10

.56)

498 7

30 (

10.8

6)36

1 707

(7.

59)

215 7

57 (

6.82

)2 4

15 57

3 (9

.94)

No4 4

11 82

8 (8

7.54

)6 0

23 42

6 (8

9.44

)4 0

91 84

8 (8

9.14

)4 4

05 04

2 (9

2.41

)2 9

48 37

0 (9

3.18

)21

880 5

14 (

90.0

6)

by guest on April 23, 2021www.aappublications.org/newsDownloaded from

HATOuN et alS134

can demonstrate important associations that inform political and health officials attempting to reduce tobacco-related morbidity or other public health concerns. However, it is important to be cautious of the ecologic fallacy with such an approach. Our independent variables, cigarette excise tax and smoke-free air grade, are based on statewide policy, however the political environment at the local level of the family interviewed for the Child ACBS could be significantly different (eg, when a family lives in a city that adds additional taxation to the state tax). Nonetheless, in our study, policy changes at the local level are only able to be stricter than state policy, possibly biasing our results toward the null hypothesis and suggesting that the results reported here are conservative estimates.

With our findings, we support ongoing efforts to reduce tobacco use. By merging state-level data with nationally representative patient data over time, we demonstrated the association between statewide policy and outcomes for pediatric asthma. Continued efforts are needed to advocate for stronger tobacco control in all states on behalf of children with asthma.

ABBREvIATIONS

aOR:  adjusted odds ratioChild ACBS:  Child Asthma

Call-Back SurveyCI:  confidence intervalSoTC:  State of Tobacco ControlTSE:  tobacco smoke exposure

REFERENCES

1. Bloom B, Jones LI, Freeman G. Summary health statistics for u.S. children: National Health Interview Survey, 2012. Vital Health Stat 10. 2013;10(258):1–81

2. Agency for Healthcare Research and Quality. Statistical brief #242: the five

most costly children’s conditions, 2006: estimates for the uS civilian noninstitutionalized children, ages 0–17. Available at: http:// meps. ahrq. gov/ mepsweb/ data_ files/ publications/ st242/ stat242. shtml. Accessed May 16, 2014

3. Adams RJ, Fuhlbrigge A, Finkelstein JA, et al. Impact of inhaled antiinflammatory therapy on hospitalization and emergency department visits for children with asthma. Pediatrics. 2001;107(4):706–711

4. Bisgaard H, Le Roux P, Bjåmer D, Dymek A, Vermeulen JH, Hultquist C. Budesonide/formoterol maintenance plus reliever therapy: a new strategy in pediatric asthma. Chest. 2006;130(6):1733–1743

5. Morkjaroenpong V, Rand CS, Butz AM, et al. Environmental tobacco smoke exposure and nocturnal symptoms among inner-city children with asthma. J Allergy Clin Immunol. 2002;110(1):147–153

6. Cook DG, Strachan DP. Health effects of passive smoking. 3. Parental smoking and prevalence of respiratory symptoms and asthma in school age children. Thorax. 1997;52(12):1081–1094

7. united States, Public Health Service, Office of the Surgeon General. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. Rockville, MD: uS Dept. of Health and Human Services, Public Health Service, Office of the Surgeon General; 2006

8. Raghuveer G, White DA, Hayman LL, et al; American Heart Association Committee on Atherosclerosis, Hypertension, and Obesity in the Young of the Council on Cardiovascular Disease in the Young; Behavior Change for Improving Health Factors Committee of the Council on Lifestyle and Cardiometabolic Health and Council on Epidemiology and Prevention; Stroke Council. Cardiovascular consequences of childhood secondhand tobacco smoke exposure: prevailing evidence, burden, and racial and socioeconomic disparities: a scientific statement from the American Heart Association

[published correction appears in Circulation. 2016;134(16):e366]. Circulation. 2016;134(16):e336–e359

9. Gerald LB, Gerald JK, Gibson L, Patel K, Zhang S, McClure LA. Changes in environmental tobacco smoke exposure and asthma morbidity among urban school children. Chest. 2009;135(4):911–916

10. Wang Z, May SM, Charoenlap S, et al. Effects of secondhand smoke exposure on asthma morbidity and health care utilization in children: a systematic review and meta-analysis. Ann Allergy Asthma Immunol. 2015;115(5):396–401.e2

11. Evans D, Levison MJ, Feldman CH, et al. The impact of passive smoking on emergency room visits of urban children with asthma. Am Rev Respir Dis. 1987;135(3):567–572

12. Chilmonczyk BA, Salmun LM, Megathlin KN, et al. Association between exposure to environmental tobacco smoke and exacerbations of asthma in children. N Engl J Med. 1993;328(23):1665–1669

13. Akinbami LJ. The state of childhood asthma, united States, 1980–2005. Adv Data Vital Stat. 2006;(381):1–24

14. Centers for Disease Control and Prevention. Disparities in secondhand smoke exposure—united States, 1988–1994 and 1999–2004. Available at: www. cdc. gov/ mmwr/ preview/ mmwrhtml/ mm5727a3. htm. Accessed June 18, 2014

15. Baxi R, Sharma M, Roseby R, et al. Family and carer smoking control programmes for reducing children’s exposure to environmental tobacco smoke. Cochrane Database Syst Rev. 2014; (3):CD001746

16. Chriqui JF, Frosh M, Brownson RC, et al. Application of a rating system to state clean indoor air laws (uSA). Tob Control. 2002;11(1):26–34

17. National Institutes of Health; National Heart, Lung, and Blood Institute. Asthma care quick reference: diagnosing and managing asthma, EPR-3 asthma guidelines. Available at: https:// www. nhlbi. nih. gov/ files/ docs/ guidelines/ asthma_ qrg. pdf. Accessed June 24, 2014

by guest on April 23, 2021www.aappublications.org/newsDownloaded from

PEDIATRICS Volume 141, number S1, January 2018 S135

18. Ma Z. use of interrupted time-series method to evaluate the impact of cigarette excise tax increases in Pennsylvania, 2000–2009. 2013. Available at: www. cdc. gov/ pcd/ issues/ 2013/ 12_ 0268. htm. Accessed November 29, 2017

19. Dove MS, Dockery DW, Connolly GN. Smoke-free air laws and asthma prevalence, symptoms, and severity among nonsmoking youth. Pediatrics. 2011;127(1):102–109

20. Been JV, Nurmatov uB, Cox B, Nawrot TS, van Schayck CP, Sheikh A. Effect of smoke-free legislation on perinatal and child health: a systematic review and meta-analysis. Lancet. 2014;383(9928):1549–1560

21. Mackay D, Haw S, Ayres JG, Fischbacher C, Pell JP. Smoke-free legislation and hospitalizations for childhood asthma. N Engl J Med. 2010;363(12): 1139–1145

22. Millett C, Lee JT, Laverty AA, Glantz SA, Majeed A. Hospital admissions for childhood asthma after smoke-free legislation in England. Pediatrics. 2013;131(2). Available at: www. pediatrics. org/ cgi/ content/ full/ 131/ 2/ e495

23. Berhane K, Chang C-C, McConnell R, et al. Association of changes in air quality with bronchitic symptoms in children in California, 1993-2012. JAMA. 2016;315(14):1491–1501

by guest on April 23, 2021www.aappublications.org/newsDownloaded from

by guest on April 23, 2021www.aappublications.org/newsDownloaded from

DOI: 10.1542/peds.2017-1026P2018;141;S130Pediatrics 

KazisJonathan Hatoun, Kendra Davis-Plourde, Brian Penti, Howard Cabral and Lewis

Tobacco Control Laws and Pediatric Asthma

ServicesUpdated Information &

http://pediatrics.aappublications.org/content/141/Supplement_1/S130including high resolution figures, can be found at:

References

#BIBLhttp://pediatrics.aappublications.org/content/141/Supplement_1/S130This article cites 16 articles, 6 of which you can access for free at:

Permissions & Licensing

http://www.aappublications.org/site/misc/Permissions.xhtmlin its entirety can be found online at: Information about reproducing this article in parts (figures, tables) or

Reprintshttp://www.aappublications.org/site/misc/reprints.xhtmlInformation about ordering reprints can be found online:

by guest on April 23, 2021www.aappublications.org/newsDownloaded from

DOI: 10.1542/peds.2017-1026P2018;141;S130Pediatrics 

KazisJonathan Hatoun, Kendra Davis-Plourde, Brian Penti, Howard Cabral and Lewis

Tobacco Control Laws and Pediatric Asthma

http://pediatrics.aappublications.org/content/141/Supplement_1/S130located on the World Wide Web at:

The online version of this article, along with updated information and services, is

by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397. the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2018has been published continuously since 1948. Pediatrics is owned, published, and trademarked by Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it

by guest on April 23, 2021www.aappublications.org/newsDownloaded from