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American Academy of Pediatrics
Commentary

Correctly Identifying Hospitalized Pediatric Patients With Tobacco Smoke Exposure: The First Step in Addressing Parental Tobacco Use

Susan C. Walley and Rachel Boykan
Hospital Pediatrics September 2019, 9 (9) 739-740; DOI: https://doi.org/10.1542/hpeds.2019-0178
Susan C. Walley
aUniversity of Alabama at Birmingham and Children’s of Alabama, Birmingham, Alabama; and
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Rachel Boykan
bSchool of Medicine, Stony Brook University and Stony Brook Children’s Hospital, Stony Brook, New York
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In their study in this issue of Hospital Pediatrics, Mahabee-Gittens et al1 compared tobacco smoke exposure (TSE) based on parental self-report in a convenience sample of pediatric patients who were hospitalized with TSE based on biochemical confirmation with levels of child salivary cotinine, a biomarker of nicotine. The study revealed poor sensitivity and specificity of parental self-report of TSE (reported in the electronic health record [EHR]), compared with measured cotinine levels. Only 67% of patients with positive cotinine levels were identified as having TSE by parental self-report, as documented in the EHR. In contrast, 77% of children with parental report of TSE who were hospitalized had positive cotinine levels. The authors concluded that almost 40% of children were misclassified in the EHR as not having TSE.

What accounts for the differences between parental self-report of TSE and biochemical measurement of salivary cotinine? The authors suggest several possibilities, including (1) their use of enzyme-linked immunosorbent assay to measure cotinine levels, which is not as sensitive as other methods; (2) the screening questions in the EHR were nonspecific, with a prompt for the nurse or physician to assess “tobacco smoke exposure” or “smokers in the home”; (3) overly general screening questions that did not determine the type of tobacco product, location, amount, and frequency of exposure.

Indeed, the way parents are asked about TSE may significantly impact responses: Groner et al2 determined sensitivity and specificity and correlation with hair nicotine levels for a variety of tobacco screening questions. They concluded that a “one size fits all” approach was insufficient and recommended universal biochemical screening for TSE.2 In several other studies, parental report was found to underestimate children’s TSE when compared with cotinine levels.3,4 By contrast, Wilson et al5 found no differences between parental report and cotinine levels measured in children seen in a pediatric emergency department.

Why is screening for TSE so important? Despite the decreasing prevalence of cigarette smoking among adults (now at 14.0% nationally), 37.9% of children 3 to 11 years old are exposed to tobacco smoke.6,7 With the rise in popularity of electronic cigarettes, also known as vapes and known by brand names such as JUUL, clinicians should also recognize the harms and inquire about potential secondhand aerosol exposure.8 This study reveals the opportunity to improve screening for all forms of TSE and to consider both universal and targeted screening and interventions. The authors conclude that universal tobacco screening should be performed, either by performing child cotinine-level testing when feasible or by “standardized and expanded TSE screening and counseling.” We agree.

Although a single, perfect, validated, universal screening question to determine child TSE is elusive, asking “Does anyone who lives in your home or who cares for your child smoke tobacco?” was shown in Groner et al2 to have a sensitivity of 74% and a positive predictive value of 88% when compared with measuring hair nicotine levels. The American Academy of Pediatrics (AAP), in the article “Clinical Practice Policy to Protect Children From Tobacco, Nicotine and Tobacco Smoke,” recommends asking in a standardized method.9 Although child cotinine-level testing may be more sensitive in picking up TSE, many institutions may not have access to cotinine-level testing that is sensitive enough for TSE.

The focus of this study was on improved screening for TSE, but the ultimate goal of identifying TSE among children who are hospitalized is to provide interventions to parents, caretakers, and patients who use tobacco products. Multiple organizations, including the National Academy of Medicine, the American Medical Association, and the AAP, recommend identification and treatment of tobacco use in health care settings, and the AAP specifically recommends providing tobacco-use treatment of parents and caretakers.9 The AAP article “Clinical Practice Policy to Protect Children From Tobacco, Nicotine, and Tobacco Smoke” provides pediatric health care providers with guidance and recommendations on the basis of the 5 A’s (ask, advise, assess, assist, and arrange).9 Additional information can be accessed on the AAP Julius B. Richmond Center of Excellence Web site: https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Richmond-Center/Pages/default.aspx.

Universal screening for TSE should be performed for all pediatric patients who are hospitalized. How that is best accomplished may vary by institution, but the ultimate goal should not: all tobacco users should be identified and offered treatment.

Footnotes

  • 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.

References

  1. ↵
    1. Mahabee-Gittens EM,
    2. Merianos A,
    3. Gordon J,
    4. et al
    . Electronic health record classification of tobacco smoke exposure and cotinine levels in hospitalized pediatric patients. Hosp Peds. 2019:9(9)
  2. ↵
    1. Groner JA,
    2. Rule AM,
    3. McGrath-Morrow SA,
    4. et al
    . Assessing pediatric tobacco exposure using parent report: comparison with hair nicotine. J Expo Sci Environ Epidemiol. 2018;28(6):530–537
    OpenUrl
  3. ↵
    1. Dempsey DA,
    2. Meyers MJ,
    3. Oh SS,
    4. et al
    . Determination of tobacco smoke exposure by plasma cotinine levels in infants and children attending urban public hospital clinics [published correction appears in JAMA Pediatr. 2014;168(8):779]. Arch Pediatr Adolesc Med. 2012;166(9):851–856
    OpenUrlCrossRefPubMed
  4. ↵
    1. Joseph A,
    2. Murphy S,
    3. Thomas J,
    4. et al
    . A pilot study of concurrent lead and cotinine screening for childhood tobacco smoke exposure: effect on parental smoking. Am J Health Promot. 2014;28(5):316–320
    OpenUrlCrossRefPubMed
  5. ↵
    1. Wilson KM,
    2. Wesgate SC,
    3. Best D,
    4. Blumkin AK,
    5. Klein JD
    . Admission screening for secondhand tobacco smoke exposure. Hosp Pediatr. 2012;2(1):26–33
    OpenUrlAbstract/FREE Full Text
  6. ↵
    1. Tsai J,
    2. Homa DM,
    3. Gentzke AS,
    4. et al
    . Exposure to secondhand smoke among nonsmokers - United States, 1988-2014. MMWR Morb Mortal Wkly Rep. 2018;67(48):1342–1346
    OpenUrl
  7. ↵
    1. Wang TW,
    2. Asman K,
    3. Gentzke AS,
    4. et al
    . Tobacco product use among adults - United States, 2017. MMWR Morb Mortal Wkly Rep. 2018;67(44):1225–1232
    OpenUrlPubMed
  8. ↵
    1. Jenssen BP,
    2. Walley SC
    ; Section on Tobacco Control. E-cigarettes and similar devices. Pediatrics. 2019;143(2):e20183652
    OpenUrlAbstract/FREE Full Text
  9. ↵
    1. Farber HJ,
    2. Walley SC,
    3. Groner JA,
    4. Nelson KE
    ; Section on Tobacco Control. Clinical practice policy to protect children from tobacco, nicotine, and tobacco smoke. Pediatrics. 2015;136(5):1008–1017
    OpenUrlAbstract/FREE Full Text
  • Copyright © 2019 by the American Academy of Pediatrics
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Correctly Identifying Hospitalized Pediatric Patients With Tobacco Smoke Exposure: The First Step in Addressing Parental Tobacco Use
Susan C. Walley, Rachel Boykan
Hospital Pediatrics Sep 2019, 9 (9) 739-740; DOI: 10.1542/hpeds.2019-0178

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Correctly Identifying Hospitalized Pediatric Patients With Tobacco Smoke Exposure: The First Step in Addressing Parental Tobacco Use
Susan C. Walley, Rachel Boykan
Hospital Pediatrics Sep 2019, 9 (9) 739-740; DOI: 10.1542/hpeds.2019-0178
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