Tobacco Smoke Exposure and Sleep Duration among U.S. Adolescents.

OBJECTIVES: Tobacco smoke exposure (TSE) and poor sleep are public health problems with their own set of consequences. This study assessed whether TSE was associated with sleep duration among U.S. adolescents. METHOD: We conducted a secondary analysis of 2013-2018 National Health and Nutrition Examination Survey data including 914 nontobacco-using adolescents ages 16-19 years. TSE measures included cotinine and self-reported home TSE groups including no home TSE, thirdhand smoke (THS) exposure, and secondhand smoke (SHS)+THS exposure. Sleep duration was assessed in hours and categorically as insufficient sleep (recommended hours). Weighted multiple linear regression and multinomial regression models were conducted. RESULTS: Adolescents with higher log-cotinine levels had higher number of sleep hours (ß = 0.31, 95%CI = 0.02,0.60) and were at increased odds of reporting excess sleep (AOR = 1.41, 95%CI = 1.40,1.42), but were at reduced odds of reporting insufficient sleep (AOR = 0.88, 95%CI = 0.87,0.89). Compared to adolescents with no home TSE, adolescents with home THS exposure and home SHS+THS exposure were at increased odds of reporting insufficient sleep (AOR = 2.27, 95%CI = 2.26,2.29; AOR = 2.75, 95%CI = 2.72,2.77, respectively) and excess sleep (AOR = 1.89, 95%CI = 1.87,1.90; AOR = 5.29, 95%CI = 5.23,5.34, respectively). CONCLUSIONS: TSE may affect insufficient and excess sleep duration among adolescents. Eliminating TSE may promote adolescent respiratory and sleep health.

Inflammatory marker levels in children with tobacco smoke exposure.

BACKGROUND: Tobacco smoke exposure (TSE) has inflammatory and immunosuppressive effects which may be associated with altered levels of inflammatory markers and pediatric illnesses. OBJECTIVE: The primary objective was to examine the associations of cotinine-confirmed and parent-reported child TSE patterns and discharge diagnoses with C-reactive protein (CRP), IL-8, and IL-10 in 0-11-year-old pediatric emergency department (PED) patients who lived with ≥ 1 smoker. METHODS: Saliva samples were obtained from 115 children with a mean (SD) age of 3.5 (3.1) years during the PED visit (T0). Saliva was analyzed for cotinine, CRP, IL-8, and IL-10. Parents self-reported their children's TSE patterns; children's medical records were reviewed to identify and categorize discharge diagnoses. Linear regression models were utilized to find T0 associations of cotinine-confirmed and parent-reported child TSE patterns, and PED diagnoses with each inflammatory marker. All models were adjusted for child race/ethnicity, child sex, annual household income, and housing type. The TSE models also adjusted for child discharge diagnosis. RESULTS: At T0, the geometric mean (GeoM) of cotinine was 4.1 ng/ml [95 %CI = 3.2-5.2]; the GeoMs of CRP, IL-8, and IL-10 were 3,326 pg/ml [95 %CI = 2,696-4,105], 474 pg/ml [95 %CI = 386-583], and 1.1 pg/ml [95 %CI = 0.9-1.3], respectively. Parent-reported child TSE patterns were positively associated with ln-transformed CRP levels, while adjusting for the covariates (ß^ = 0.012 [95 %CI:0.004-0.020], p = 0.037). In the parent-reported child TSE pattern model, there were significant positive associations between the covariate of child age with CRP and IL-8 levels (p = 0.028 and p < 0.001, respectively). Children with a bacterial diagnosis had higher IL-8 levels (p = 0.002) compared to the other diagnosis groups. CONCLUSIONS: Results indicate that parent-reported child TSE increases the expression of CRP in ill children and supports prior work demonstrating that IL-8 is higher in children with TSE who have bacterial infections. These findings should be examined in future research with ill children with and without TSE.

Contamination of surfaces in children's homes with nicotine and the potent carcinogenic tobacco-specific nitrosamine NNK.

BACKGROUND: Tobacco smoke exposure (TSE) through secondhand and thirdhand smoke is a modifiable risk factor that contributes to childhood morbidity. Limited research has assessed surface TSE pollution in children's environments as a potential source of thirdhand smoke exposure, and none have examined levels of the tobacco-specific nitrosamine 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK) on surfaces. OBJECTIVE: This study measured surface NNK and nicotine in children's homes and associations with sociodemographics and parent-reported TSE behaviors. We assessed correlations of surface NNK and nicotine with dust NNK, dust nicotine, and child cotinine. METHODS: Home surface wipe NNK and nicotine data from 84 children who lived with smokers were analyzed. Tobit and simple linear regression analyses were conducted to assess associations of surface NNK and nicotine with child characteristics. Spearman's (ρ) correlations assessed the strength of associations between environmental markers and child cotinine. RESULTS: Nearly half (48.8%) of children's home surfaces had detectable NNK and 100% had detectable nicotine. The respective geometric means (GMs) of surface NNK and nicotine loadings were 14.0 ng/m2 and 16.4 µg/m2. Surface NNK positively correlated with surface nicotine (ρ = 0.54, p < 0.001) and dust NNK (ρ = 0.30, p = 0.020). Surface nicotine positively correlated with dust NNK (ρ = 0.42, p < 0.001) and dust nicotine (ρ = 0.24, p = 0.041). Children with household incomes ≤$15,000 had higher surface NNK levels (GM = 18.7 ng/m2, p = 0.017) compared to children with household incomes >$15,000 (GM = 7.1 ng/m2). Children with no home smoking bans had higher surface NNK (GM = 18.1 ng/m2, p = 0.020) and surface nicotine (GM = 17.7 µg/m2, p = 0.019) levels compared to children with smoking bans (GM = 7.5 ng/m2, 4.8 µg/m2, respectively). IMPACT: Although nicotine on surfaces is an established marker of thirdhand smoke pollution, other thirdhand smoke contaminants have not been measured on surfaces in the homes of children living with smokers. We provide evidence that the potent carcinogenic tobacco-specific nitrosamine NNK was detectable on surfaces in nearly half of children's homes, and nicotine was detectable on all surfaces. Surface NNK was positively correlated with surface nicotine and dust NNK. Detectable surface NNK levels were found in homes with indoor smoking bans, indicating the role of NNK as a persistent thirdhand smoke pollutant accumulating on surfaces as well as in dust.

Adverse Childhood Experiences and Electronic Cigarette Use among U.S. Young Adults.

(1) Background: Adverse childhood experiences (ACEs), which are potentially traumatic childhood events, have been associated with increased tobacco product use. Less is known about electronic cigarette (e-cigarette) use during young adulthood. This study explored the associations between ACEs and current e-cigarette use among U.S. young adults. (2) Methods: This study was a secondary analysis of 2021 Behavioral Risk Factor Surveillance System data including 2537 young adults aged 18-24 years. Unadjusted and adjusted logistic regression analyses were conducted. (3) Results: Of the participants, 19.2% currently used e-cigarettes, and 22.1% reported 1 ACE, 13.0% reported 2 ACEs, 10.7% reported 3 ACEs, and 30.6% reported ≥4 ACEs. Unadjusted results indicated that participants who experienced 1 ACE (odds ratio (OR) = 1.76, 95% confidence interval (CI) = 1.01-3.07), 2 ACEs (OR = 2.18, 95%CI = 1.24-3.83), 3 ACEs (OR = 2.63, 95%CI = 1.41-4.90), and ≥4 ACEs (OR = 3.69, 95%CI = 2.23-6.09) were at increased odds of reporting current e-cigarette use than participants who experienced 0 ACEs. Adjusted results indicated that participants who experienced 3 ACEs were at 2.20 times higher odds (95%CI = 1.15-4.23) and participants who experienced ≥4 ACEs were at 2.73 times higher odds (95%CI = 1.58-4.71) of reporting current e-cigarette use than participants who experienced 0 ACEs. (4) Conclusions: Young adults exposed to ACEs are at risk of using e-cigarettes.

Changes and stability of hand nicotine levels in children of smokers: Associations with urinary biomarkers, reported child tobacco smoke exposure, and home smoking bans.

BACKGROUND: Exposure to thirdhand smoke (THS) residue takes place through inhalation, ingestion, and dermal transfer. Hand nicotine levels have been proposed to measure THS pollution in the environment of children, but little is known about its variability and stability over time and correlates of change. OBJECTIVES: The goal was to determine the stability of hand nicotine in comparison to urinary biomarkers and to explore factors that influence changes in hand nicotine. METHODS: Data were collected from 0 to 11-year-old children (Mean age = 5.9) who lived with ≥1 tobacco smokers (N = 129). At a 6-week interval, we collected repeated measures of hand nicotine, four urinary biomarkers (cotinine, trans-3'-hydroxycotinine, nicotelline N-oxides, and 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol), and parent-reported child tobacco smoke exposure (TSE). Dependent sample t-tests, correlations, and multivariable regression analyses were conducted to examine the changes in child TSE. RESULTS: Hand nicotine levels (r = 0.63, p < 0.001) showed similar correlations between repeated measures to urinary biomarkers (r = 0.58-0.71; p < 0.001). Different from urinary biomarkers, mean hand nicotine levels increased over time (t(113) = 3.37, p < 0.001) being significantly higher in children from homes without smoking bans at Time 2 (p = 0.016) compared to Time 1 (p = 0.003). Changes in hand nicotine correlated with changes in cotinine and trans-3'-hydroxycotinine (r = 0.30 and r = 0.19, respectively, p < 0.05). Children with home smoking bans at Time 1 and 2 showed significantly lower hand nicotine levels compared to children without home smoking bans. DISCUSSION: Findings indicate that hand nicotine levels provide additional insights into children's exposure to tobacco smoke pollutants than reported child TSE and urinary biomarkers. Changes in hand nicotine levels show that consistent home smoking bans in homes of children of smokers can lower THS exposure. Hand nicotine levels may be influenced by the environmental settings in which they are collected.

Electronic cigarette use and cigarette smoking associated with inadequate sleep duration among U.S. young adults.

OBJECTIVE: Nicotine use can influence inadequate sleep, but less is known about the associations of exclusive and dual use of electronic cigarettes (e-cigarettes) with combustible cigarettes in U.S. young adults. This study assessed the associations between current exclusive e-cigarette use, exclusive cigarette smoking, and dual e-cigarette and combustible cigarette use and inadequate sleep duration among U.S. young adults. METHODS: We performed a secondary analysis of 2020 Behavioral Risk Factor Surveillance System (BRFSS) data including 13,978 U.S. young adults ages 18-24 years. Inadequate sleep duration was assessed categorically using the National Sleep Foundation's age-specific recommendations that define <7 h as inadequate sleep. Weighted logistic regression models were performed while adjusting for participants' sex, race/ethnicity, education level, annual household income level, body mass index, current physical activity, mental health status, disability status, current alcohol use, and current smokeless tobacco use. RESULTS: Concerning use patterns, 11.8% of young adults were exclusive e-cigarette users, 4.7% were exclusive cigarette smokers, and 3.8% were dual e-cigarette and combustible cigarette users. Exclusive e-cigarette users (adjusted odds ratio [AOR] = 1.41, 95% confidence interval [CI] = 1.16-1.72), exclusive cigarette smokers (AOR = 1.63, 95%CI = 1.22-2.18), and dual product users (AOR = 2.03, 95%CI = 1.44-2.86) were at increased odds of having inadequate sleep duration compared to non-users, while adjusting for the covariates. Additionally, dual product users were at increased odds (AOR = 1.52, 95%CI = 1.06-2.19) of reporting inadequate sleep duration compared to exclusive e-cigarette users, while adjusting for the covariates. CONCLUSIONS: Current e-cigarette and cigarette use may influence inadequate sleep among U.S. young adults. Tobacco cessation efforts may encourage increased sleep health.

Association of self-reported use of cannabis for the purpose of improving physical, mental, and sleep health with problematic cannabis use risk.

BACKGROUND: Little is known about health-focused cannabis use purposes and their associations with risk for problematic cannabis use. This cross-sectional study examined three broad cannabis use purposes and association with risk for problematic use among young adult cannabis users who report using for > 1 health reasons. METHODS: Young adults completed an electronic survey as part of an ongoing study on substance use and health. Those who self-reported past 6-month use of ≥ 1 cannabis products-smoking, vaping, dabbing, eating, and blunts-were included in the analysis. Their purposes for use were coded into three categories: sleep, mental, and physical health. Problematic cannabis use (PCU) was measured with the three-level structure Cannabis Abuse Screening Test (CAST-3). Adjusted multivariable regression models were used to estimate use purposes associated with with problematic cannabis use at the p < 0.05 level. RESULTS: Participants (n = 954) were mostly female (63.94%) and Hispanic (54.93%). Mental health was the most endorsed reason (73.38%) for use among study sample. Among participants, 36.3% were classified as being at severe risk (CAST-3 score ≥ 8). There was a significant association between PCU risk and reporting cannabis use for physical health (p < 0.01), mental health, and sleep health (p < 0.01) purposes. Those who used cannabis for physical heath purposes had about four times the risk (adjusted relative risk ratio (aRRR) = 4.38, 95% CI = 3.06-6.69), those who used for mental health had about three times the risk (aRRR = 2.81, 95% CI = 1.86-4.72), and those who used for sleep health had almost two times the risk (aRRR = 1.83, 95% CI = 1.17-2.63) for severe PCU. CONCLUSION: All cannabis use purposes examined increased risk of problematic cannabis use. Physical health use purposes was associated with highest PCU risk. This study demonstrates the risk for cannabis use disorder associated with self-medicating with cannabis.

"I Don't Want My Child to Be a Guinea Pig": Reasons for Non-Participation in a Parental Tobacco Cessation Trial in the Pediatric Emergency Department Setting.

(1) Background: Pediatric emergency department (PED) settings are opportune venues in which to recruit parental smokers into tobacco cessation interventions. However, the barriers associated with parents' participation in PED-based cessation trials are unknown. The objective was to explore parents' reasons for non-participation in a PED-based tobacco cessation trial. (2) Methods: We employed the framework method and conducted a qualitative data analysis of parental smokers who were eligible to participate in a PED-based tobacco cessation trial and did not choose to participate (n = 371). (3) Results: Two main themes emerged about reasons for non-participation: (a) Not interested in participating in a research study, and (b) concerns specific to the study. Parents had various reasons for not participating in the cessation trial including not being interested in quitting, parents' health and well-being, parents' beliefs about research, and time required for the study and follow-up visits. (4) Conclusion: General disinterest and specific study-related concerns were touted as reasons for non-participation in a PED-based tobacco cessation trial. Given the potential reductions in tobacco-related morbidity to both parents and children that tobacco control interventions can facilitate, future tobacco interventions should consider alterations in study design and recruitment strategies to encourage all eligible parental smokers to participate.

Policy-relevant differences between secondhand and thirdhand smoke: strengthening protections from involuntary exposure to tobacco smoke pollutants.

Starting in the 1970s, individuals, businesses and the public have increasingly benefited from policies prohibiting smoking indoors, saving thousands of lives and billions of dollars in healthcare expenditures. Smokefree policies to protect against secondhand smoke exposure, however, do not fully protect the public from the persistent and toxic chemical residues from tobacco smoke (also known as thirdhand smoke) that linger in indoor environments for years after smoking stops. Nor do these policies address the economic costs that individuals, businesses and the public bear in their attempts to remediate this toxic residue. We discuss policy-relevant differences between secondhand smoke and thirdhand smoke exposure: persistent pollutant reservoirs, pollutant transport, routes of exposure, the time gap between initial cause and effect, and remediation and disposal. We examine four policy considerations to better protect the public from involuntary exposure to tobacco smoke pollutants from all sources. We call for (a) redefining smokefree as free of tobacco smoke pollutants from secondhand and thirdhand smoke; (b) eliminating exemptions to comprehensive smoking bans; (c) identifying indoor environments with significant thirdhand smoke reservoirs; and (d) remediating thirdhand smoke. We use the case of California as an example of how secondhand smoke-protective laws may be strengthened to encompass thirdhand smoke protections. The health risks and economic costs of thirdhand smoke require that smokefree policies, environmental protections, real estate and rental disclosure policies, tenant protections, and consumer protection laws be strengthened to ensure that the public is fully protected from and informed about the risks of thirdhand smoke exposure.

The Associations of Trans-3'-Hydroxy Cotinine, Cotinine, and the Nicotine Metabolite Ratio in Pediatric Patients with Tobacco Smoke Exposure.

(1) Background: Trans-3'-hydroxy cotinine (3HC) and cotinine (COT) are tobacco smoke exposure (TSE) biomarkers and the 3HC/COT ratio is a marker of CYP2A6 activity, an enzyme which metabolizes nicotine. The primary objective was to assess the associations of these TSE biomarkers with sociodemographics and TSE patterns in children who lived with ≥1 smoker. (2) Methods: A convenience sample of 288 children (mean age (SD) = 6.42 (4.8) years) was recruited. Multiple linear regression models were built to assess associations of sociodemographics and TSE patterns with urinary biomarker response variables: (1) 3HC, (2) COT, (3) 3HC+COT sum, and (4) 3HC/COT ratio. (3) Results: All children had detectable 3HC (Geometric Mean [GeoM] = 32.03 ng/mL, 95%CI = 26.97, 38.04) and COT (GeoM = 10.24 ng/mL, 95%CI = 8.82, 11.89). Children with higher cumulative TSE had higher 3HC and COT (ß^ = 0.03, 95%CI = 0.01, 0.06, p = 0.015 and ß^ = 0.03, 95%CI = 0.01, 0.05, p = 0.013, respectively). Highest 3HC+COT sum levels were in children who were Black (ß^ = 0.60, 95%CI = 0.04, 1.17, p = 0.039) and who had higher cumulative TSE (ß^ = 0.03, 95%CI = 0.01, 0.06, p = 0.015). Lowest 3HC/COT ratios were in children who were Black (ß^ = -0.42, 95%CI = -0.78, -0.07, p = 0.021) and female (ß^ = -0.32, 95%CI = -0.62, -0.01, p = 0.044). (4) Conclusion: Results indicate that there are racial and age-related differences in TSE, most likely due to slower nicotine metabolism in non-Hispanic Black children and in younger children.

Current tobacco use patterns associated with healthcare utilization among non-Hispanic Black and Hispanic men with chronic conditions.

INTRODUCTION: Tobacco use disparities persist among U.S. adults who are male, racially/ethnically diverse, and have chronic conditions. This study assessed current tobacco use patterns associated with past year healthcare utilization among non-Hispanic Black and Hispanic men ≥40 years old with ≥1 chronic condition. METHODS: Data were collected from a sample of 1,904 non-Hispanic Black and Hispanic men from across the U.S. using an internet-delivered survey. Participants were categorized into four tobacco use groups: nontobacco users, exclusive cigarette smokers, dualtobacco users (cigarettes + one other tobacco product), and polytobacco users (cigarettes + ≥2 other tobacco products). Logistic regression analyses were conducted to assess current tobacco use patterns with past year primary care visits, emergency department (ED) visits, and overnight hospital stays. Adjusted models included participants' age, race/ethnicity, education level, marital status, health insurance coverage, body mass index, and number of chronic conditions. RESULTS: Relative to nontobacco users, exclusive cigarette smokers were at decreased odds of having a past year primary care visit (adjusted odds ratio [AOR] = 0.68, 95% confidence interval [CI] = 0.47-0.99). Exclusive cigarette smokers (AOR = 1.66, 95%CI = 1.25-2.19), dualtobacco users (AOR = 1.75, 95%CI = 1.23-2.50), and polytobacco users (AOR = 4.10, 95%CI = 2.46-6.84) were at increased odds of having a past year ED visit compared to nontobacco users. Additionally, polytobacco users were at increased odds of having a past year overnight hospital stay (AOR = 2.72, 95%CI = 1.73-4.29) compared to nontobacco users. CONCLUSIONS: Findings suggest current tobacco use patterns are uniquely associated with past year healthcare utilization among non-Hispanic Black and Hispanic men, while taking into consideration important factors including complex disease profiles.

Tobacco Smoke Exposure and Gastrointestinal Problems Among US Children.

This study examined the association between home tobacco smoke exposure (TSE) status and gastrointestinal problems in the past 12 months among US children. We conducted a secondary analysis of the 2018-2019 National Survey of Children's Health cross-sectional data including 20 149 children aged 4 to 10 years. Weighted logistic regression models unadjusted and adjusted for child and family covariates were fitted. Overall, 12.3% of children had home thirdhand smoke (THS) exposure only and 1.8% had home secondhand smoke (SHS) and THS exposure. Unadjusted (odds ratio [OR] = 1.70, 95% confidence interval [CI] = 1.32-2.20) and adjusted (adjusted odds ratio [AOR] = 1.51, 95% CI = 1.14-1.99) logistic regression results indicated that relative to children with no home TSE, children with home THS exposure only were at increased odds of having frequent or chronic difficulty with gastrointestinal problems over the past 12 months. Interventions are critically needed to promote smoking cessation among household members who live with children in order to reduce levels of SHS and THS in their homes.

Associations of household tobacco smoking status with childhood temperament among U.S. preschool-aged children.

BACKGROUND: This study investigated the association between household tobacco smoking status and temperament among U.S. 3-5-year-olds. METHODS: A secondary analysis of 2019-2020 National Survey of Children's Health data (N = 11,100) was conducted. Temperament dimensions of effortful control (characterized by attention focusing), negative affectivity (characterized by anger and soothability), and surgency (characterized by activity level and shyness) were assessed. Weighted ordinal regression models were conducted while adjusting for child and family covariates. RESULTS: Approximately 13 % of children lived with smokers. Compared to children who did not live with smokers, children living with smokers displayed behaviors of poorer effortful control and were more likely to be easily distracted (AOR = 1.59, 95%CI = 1.24-2.04) and less likely to keep working on tasks until finished (AOR = 0.56, 95%CI = 0.44-0.71). Children living with smokers displayed behaviors of greater negative affectivity and were at increased odds of being angry or anxious when transitioning between activities (AOR = 1.50, 95%CI = 1.13-1.98) and losing their temper when things did not go their way (AOR = 1.53, 95%CI = 1.20-1.96), and were at decreased odds of calming down quickly when excited (AOR = 0.54, 95%CI = 0.42-0.70). Children living with smokers displayed behaviors of poorer surgency and were less likely to play well with others (AOR = 0.58, 95%CI = 0.45-0.76) and sit still compared to same-aged children (AOR = 0.56, 95%CI = 0.44-0.71). LIMITATIONS: The NSCH uses a cross-sectional survey design; longitudinal associations and objective measures could not be assessed. However, the NSCH is nationally representative and results are generalizable to U.S. 3-5-year-olds. CONCLUSIONS: Findings suggest household tobacco smoking influences temperament in early childhood. Results signify the need to promote household tobacco cessation.

Distinguishing Exposure to Secondhand and Thirdhand Tobacco Smoke among U.S. Children Using Machine Learning: NHANES 2013-2016.

While the thirdhand smoke (THS) residue from tobacco smoke has been recognized as a distinct public health hazard, there are currently no gold standard biomarkers to differentiate THS from secondhand smoke (SHS) exposure. This study used machine learning algorithms to assess which combinations of biomarkers and reported tobacco smoke exposure measures best differentiate children into three groups: no/minimal tobacco smoke exposure (NEG); predominant THS exposure (TEG); and mixed SHS and THS exposure (MEG). Participants were 4485 nonsmoking 3-17-year-olds from the National Health and Nutrition Examination Survey 2013-2016. We fitted and tested random forest models, and the majority (76%) of children were classified in NEG, 16% were classified in TEG, and 8% were classified in MEG. The final classification model based on reported exposure, biomarker, and biomarker ratio variables had a prediction accuracy of 95%. This final model had prediction accuracies of 100% for NEG, 88% for TEG, followed by 71% for MEG. The most important predictors were the reported number of household smokers, serum cotinine, serum hydroxycotinine, and urinary 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL). In the absence of validated biomarkers specific to THS, comprehensive biomarker and questionnaire data for tobacco smoke exposure can distinguish children exposed to SHS and THS with high accuracy.

E-Cigarette and Cannabis Use Patterns, Depression, and Suicide Behaviors Among US Youth: Analysis of 2019 Youth Risk Behavior Survey Data.

PURPOSE: To examine the associations of current electronic cigarette and cannabis use patterns with depression symptoms and suicidal ideation and behavior overall and stratified by sex among U.S. high school students. DESIGN: Quantitative, cross-sectional study. SETTING: The 2019 National Youth Risk Behavior Survey. SUBJECTS: 12,401 high school students in 9th-12th grade. MEASURES: Dependent variables were depression symptoms, suicidal ideation, suicide plan, suicide attempt, and suicide attempt-related injury. Independent variables were past 30 day e-cigarette and cannabis use patterns. Covariates included demographics, grade level, and other tobacco product use. ANALYSIS: Multivariable logistic regression models. RESULTS: Approximately 15.7% of students were exclusive e-cigarette users, 4.5% were exclusive cannabis users, and 16.4% were concurrent e-cigarette and cannabis users. Exclusive e-cigarette and cannabis users, and concurrent users were at increased odds (P < .05) of having depression symptoms, seriously considered attempting suicide, planning suicide, suicide attempt, and having suicide attempt-related injury compared to non-users. Female users, especially concurrent users, had higher odds of reporting depression symptoms (P < .01) and all suicidal ideation and behavior outcomes (P < .01) than female non-users, but results varied for male students. CONCLUSION: E-cigarette and cannabis use patterns significantly predicted depression symptomatology and suicidal ideation and behavior, with female students having higher odds. Results suggest the need for tailored interventions to address mental health and suicidality among U.S. adolescents, and especially female students.

Carcinogenic and tobacco smoke-derived particulate matter biomarker uptake and associated healthcare patterns among children.

BACKGROUND: The objective was to assess the associations of child tobacco smoke exposure (TSE) biomarkers (urinary cotinine, NNAL, and nicotelline N-oxides) and parent-reported smoking and child TSE patterns with total hospital visits, pediatric emergency department (PED) visits, urgent care (UC), revisits, and hospital admissions among 0-9-year-olds. METHODS: A convenience sample of PED/UC patients (N = 242) who presented to a large, US children's hospital who had baseline urine samples assayed for the TSE biomarkers of interest were included. Biomarker levels were log-transformed, and linear and Poisson regression models were built. RESULTS: The geometric means of child cotinine, creatinine-adjusted NNAL, and N-oxide levels were 11.2 ng/ml, 30.9 pg/mg creatinine, and 24.1 pg/ml, respectively. The mean (SD) number of daily cigarettes smoked by parents was 10.2 (6.1) cigarettes. Each one-unit increase in log-NNAL levels was associated with an increase in total UC visits (aRR = 1.68, 95% CI = 1.18-2.39) among 0-9-year-olds, while controlling for the covariates. Each one-unit increase in child log-NNAL/cotinine ratio (×103) values was associated with an increase in total hospital visits (aRR = 1.39, 95% CI = 1.10-1.75) and UC visits (aRR = 1.56, 95% CI = 1.14-2.13) over 6 months. CONCLUSION: Systematic screening for child TSE should be conducted during all hospital visits. The comprehensive assessment of TSE biomarkers should be considered to objectively measure young children's exposure. IMPACT: Higher levels of cotinine, a widely used tobacco smoke exposure biomarker, have been associated with higher healthcare utilization patterns among children. Less is known on the associations of carcinogenic and tobacco smoke-derived particulate matter biomarker uptake with child healthcare utilization patterns. This study assessed the associations of several biomarkers with healthcare utilization patterns among pediatric emergency department patients ages 0-9 years who lived with tobacco smokers. Higher urinary NNAL biomarker levels, in individual and ratio form with cotinine, increased children's risk for urgent care visits over 6 months. Higher parent-reported cumulative child tobacco smoke exposure increased children's risk for hospital admissions.

Sources of Tobacco Smoke Exposure and Their Associations With Serum Cotinine Levels Among US Children and Adolescents.

INTRODUCTION: We assessed tobacco smoke exposure (TSE) levels based on private and public locations of TSE according to race and ethnicity among US school-aged children ages 6-11 years and adolescents ages 12-17 years. AIMS AND METHODS: Data were from 5296 children and adolescents who participated in the National Health and Nutrition Examination Survey (NHANES) 2013-2018. Racial and ethnic groups were non-Hispanic white, black, other or multiracial, and Hispanic. NHANES assessed serum cotinine and the following TSE locations: homes and whether smokers did not smoke indoors (home thirdhand smoke [THS] exposure proxy) or smoked indoors (secondhand [SHS] and THS exposure proxy), cars, in other homes, restaurants, or any other indoor area. We used stratified weighted linear regression models by racial and ethnic groups and assessed the variance in cotinine levels explained by each location within each age group. RESULTS: Among 6-11-year-olds, exposure to home THS only and home SHS + THS predicted higher log-cotinine among all racial and ethnic groups. Non-Hispanic white children exposed to car TSE had higher log-cotinine (ß = 1.64, 95% confidence interval [CI] = 0.91% to 2.37%) compared to those unexposed. Non-Hispanic other/multiracial children exposed to restaurant TSE had higher log-cotinine (ß = 1.13, 95% CI = 0.23% to 2.03%) compared to those unexposed. Among 12-17-year-olds, home SHS + THS exposure predicted higher log-cotinine among all racial and ethnic groups, except for non-Hispanic black adolescents. Car TSE predicted higher log-cotinine among all racial and ethnic groups. Non-Hispanic black adolescents with TSE in another indoor area had higher log-cotinine (ß = 2.84, 95% CI = 0.85% to 4.83%) compared to those unexposed. CONCLUSIONS: TSE location was uniquely associated with cotinine levels by race and ethnicity. Smoke-free home and car legislation are needed to reduce TSE among children and adolescents of all racial and ethnic backgrounds. IMPLICATIONS: Racial and ethnic disparities in TSE trends have remained stable among US children and adolescents over time. This study's results indicate that TSE locations differentially contribute to biochemically measured TSE within racial and ethnic groups. Home TSE significantly contributed to cotinine levels among school-aged children 6-11 years old, and car TSE significantly contributed to cotinine levels among adolescents 12-17 years old. Racial and ethnic differences in locations of TSE were observed among each age group. Study findings provide unique insight into TSE sources, and indicate that home and car smoke-free legislation have great potential to reduce TSE among youth of all racial and ethnic backgrounds.

Stealth vaping and associated attitudes, perceptions, and control beliefs among US college students across four tobacco-free campuses.

OBJECTIVES: Stealth vaping gained popularity among college students in recent years. It may undermine the benefits introduced by tobacco-free policies. Yet, no studies have investigated attitude and belief factors associated with stealth vaping. The objective of the study was to explore the relationship between attitudes toward on-campus tobacco regulations, normative perceptions of stealth vaping behaviors, and control beliefs with on-campus stealth vaping among U.S. college students. METHODS: Participants from four large, public universities with policies prohibiting use of all forms of tobacco (including e-cigarettes) on campus (N = 863) completed an online survey in Fall 2020. On-campus stealth vaping behavior was captured by past 30-day stealth vaping status and frequency. Hurdle models with logistic and negative binomial regressions were conducted, where stealth vaping status was treated as a binary variable based on the non-zero and zero frequency, and stealth vaping frequency was treated as a count variable. Multiple imputation by chained equations was employed to handle the missing data. RESULTS: Participants with more positive attitudes toward regulating on-campus tobacco use were less likely to practice stealth vaping on campus (OR = 1.16, p < 0.01 [predicting zero]). Those with higher perceptions of stealth vaping among other students were more likely to stealth vape more frequently (IRR = 1.03, p < 0.01). CONCLUSION: Our results highlight the need for interventions to address students' attitudes and normative beliefs about stealth vaping. Efforts are needed to educate college students about the risk of e-cigarettes and to enhance enforcement of campus tobacco-free policies.

Child Tobacco Smoke Exposure, Indoor Home Characteristics, and Housing Stability among a National Sample of U.S. Children.

(1) Objectives: To examine the associations of child tobacco smoke exposure (TSE) with home quality and housing instability. (2) Methods. A secondary analysis of 32,066 U.S. 0-11-year-old children from the 2018-2019 National Survey of Children's Health was conducted. Child home TSE status was defined as: no TSE: child lived with no smokers; thirdhand smoke (THS) exposure only: child lived with a smoker(s) who did not smoke indoors; and secondhand smoke (SHS) and THS exposure: child lived with a smoker(s) who smoked indoors. Home quality was assessed by the presence of mold or pesticide use and housing instability was assessed by home ownership, frequency of moves, and number of household members. We conducted weighted multivariable logistic regression and linear regression models while adjusting for important child covariates. (3) Results: In total, 12.3% had home THS exposure only and 1.6% had home SHS and THS exposure. Compared to children with no home TSE, children with home SHS and THS exposure were 2.60 times more likely (95%CI = 1.73, 3.92) to have mold inside their homes; 1.57 times more likely (95%CI = 1.09, 2.26) to live in homes where pesticides were used ≥1 time during the past 12-months; and more likely to have more frequent moves (ß = 1.06, 95%CI = 0.62, 1.50). (4) Conclusions: Children with home TSE have higher rates of mold, pesticide use, frequent moves, and household members compared to children with no home TSE. Children with TSE should also be screened for home quality and housing instability and provided with appropriate interventions and resources.

High Levels of the Carcinogenic Tobacco-Specific Nitrosamine NNAL and Associated Findings in Children of Smokers: A Case Series.

High levels of NNAL, the tobacco smoke exposure (TSE) biomarker of the carcinogen 4-(Methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK), indicate future cancer risk. A prior study of smokers' children revealed NNAL levels as high as active smokers. Therefore, we conducted a case series to examine the sociodemographics, TSE and clinical patterns, and other TSE biomarker levels in 9 children with extreme NNAL levels of >200 pg/ml to generate hypotheses and explore potential causes and implications. We identified 0 to 4-year-olds who presented to an emergency setting and lived with ⩾1 smoker who were part of a parental tobacco cessation trial (n = 461). Of these children, 52 had urinary NNAL, cotinine, and N-oxides results (n = 52). Nine children (17.3%) had NNAL levels >200 pg/ml, ranging from 206.4 to 1399.0 pg/ml (Median (Mdn) = 489.2 pg/ml; Interquartile Range (IQR) = 222.7-1289.3 pg/ml). The cotinine Mdn (IQR) was 38.5 (10.3-102.2) ng/ml and the N-oxides Mdn (IQR) = 93.8 (24.7-109.6) pg/ml. While all biomarker levels were alarmingly high, these young children would not have been flagged for very high cancer risk based on urinary cotinine levels alone. This underscores the critical role of comprehensive TSE biomarker measurement in capturing different TSE exposure patterns and assessing children's future risk for cancer and other TSE-related morbidities.