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.

Perception of harm is strongly associated with complete ban on in-home cannabis smoking: a cross-sectional study.

BACKGROUND: Perception of health risk can influence household rules, but little is known about how the perception of harm from cannabis secondhand smoke (cSHS) is related to having a complete ban on in-home cannabis smoking. We examined this association among a nationally representative sample of United States adults. METHODS: Respondents were 21,381 adults from the cross-sectional Marijuana Use and Environmental Survey recruited from December 2019-February 2020. Perceived harm of cSHS exposure (extremely harmful, somewhat harmful, mostly safe, or totally safe) and complete ban of cannabis smoking anywhere in the home (yes or no) were self-reported. Logistic regression for survey-weighted data estimated covariate-adjusted odds ratios (OR) and 95% confidence intervals (CI) for the association between perceived harm of cSHS and complete ban on in-home cannabis smoking. Stratified subgroup analyses (by cannabis smoking status, cannabis use legalization in state of residence, and children under age 6 living in the home) were conducted to quantify effect measure modification of the association between perception of harm and complete ban. RESULTS: A complete ban on in-home cannabis smoking was reported by 71.8% of respondents. Eight percent reported cSHS as "totally safe"; 20.5% "mostly safe"; 38.3% "somewhat harmful"; and 33.0% "extremely harmful". Those who reported cSHS as "extremely harmful" had 6 times the odds of a complete ban on in-home cannabis smoking (OR = 6.0, 95%CI = 4.9-7.2) as those reporting smoking as "totally safe". The odds of a complete ban were higher among those reporting cSHS as "somewhat harmful" (OR = 2.6, 95%CI = 2.2-3.1) or "mostly safe" (OR = 1.4, 95%CI = 1.2-1.7) vs those reporting cSHS as "totally safe". In each subgroup of cannabis smoking status, state cannabis use legalization, and children under the age of 6 living in the home, perceived harm was associated with a complete ban on in-home cannabis smoking. CONCLUSIONS: Our study demonstrates perceiving cSHS as harmful is strongly associated with having a complete in-home cannabis smoking ban. With almost a third of US adults perceiving cSHS as at least "mostly safe", there is strong need to educate the general population about potential risks associated with cSHS exposure to raise awareness and encourage adoption of household rules prohibiting indoor cannabis smoking.

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.

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.

Evaluation of a Social Media Campaign Designed to Increase Awareness of Thirdhand Smoke among California Adults.

Despite a growing body of research outlining the harms of thirdhand smoke (THS), the public remains generally unaware of risks and exposure routes. This project built on past tobacco prevention campaigns and the tenants of McGuire's input-output model to implement and evaluate a seven-month Facebook-disseminated campaign seeking to improve THS awareness among California adults (n = 1087). Multilinear regression showed that THS-related knowledge (χ2[6] = 19.31, p < .01), attitude (χ2[6] = 13.88, p < .05), and efficacy (χ2[6] = 13.81, p < .05) significantly increased by the campaign's end, with messages highlighting children's health (r = .110, p < .05), pets (r = .145, p < .01), and dust reservoirs (r = .144, p < .01) as the most persuasive. Path analysis modeling found campaign recall to be associated with changes in knowledge (ß = .161, p < .01), which predicated attitude change (ß = .614, p < .001) and, in turn, behavior change (ß = .149, p < .05). Findings suggest social media campaigns should continue to educate diverse populations about new tobacco risks and that tobacco control advocates should consider integrating educational THS messages.

Thirdhand Exposures to Tobacco-Specific Nitrosamines through Inhalation, Dust Ingestion, Dermal Uptake, and Epidermal Chemistry.

Tobacco-specific nitrosamines (TSNAs) are emitted during smoking and form indoors by nitrosation of nicotine. Two of them, N'-nitrosonornicotine (NNN) and 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK), are human carcinogens with No Significant Risk Levels (NSRLs) of 500 and 14 ng day-1, respectively. Another TSNA, 4-(methylnitrosamino)-4-(3-pyridyl) butanal (NNA), shows genotoxic and mutagenic activity in vitro. Here, we present additional evidence of genotoxicity of NNA, an assessment of TSNA dermal uptake, and predicted exposure risks through different pathways. Dermal uptake was investigated by evaluating the penetration of NNK and nicotine through mice skin. Comparable mouse urine metabolite profiles suggested that both compounds were absorbed and metabolized via similar mechanisms. We then investigated the effects of skin constituents on the reaction of adsorbed nicotine with nitrous acid (epidermal chemistry). Higher TSNA concentrations were formed on cellulose and cotton substrates that were precoated with human skin oils and sweat compared to clean substrates. These results were combined with reported air, dust, and surface concentrations to assess NNK intake. Five different exposure pathways exceeded the NSRL under realistic scenarios, including inhalation, dust ingestion, direct dermal contact, gas-to-skin deposition, and epidermal nitrosation of nicotine. These results illustrate potential long-term health risks for nonsmokers in homes contaminated with thirdhand tobacco smoke.

Thirdhand Smoke Knowledge, Attitudes, and Behavior: Development of Reliable and Valid Self-report Measures.

INTRODUCTION: This study sought to provide essential tobacco control tools by testing the reliability and validity of new self-report scales developed to assess thirdhand smoke (THS) (ie, toxic tobacco residue) related knowledge, attitudes, and behavior (KAB). AIMS AND METHODS: Items for the KAB scales were adapted from established secondhand smoke (SHS) measures, reviewed to support face validity, and tested in a longitudinal online survey evaluating THS health messages. Participants were California adults at risk of THS exposure. For 7 months, the three KAB scales were completed monthly, and data from the first (n = 1086), third (n = 315), and seventh (n = 301) month surveys were used in these analyses. RESULTS: All three scales demonstrated consistent reliability and single-factor loading at all three timepoints for knowledge (αrange: .87-.90), attitude (αrange: .84-.87), and behavior (αrange: .80-.86). Similarly, analyses supported scale convergent validity (scale correlations rrange: .45-.85; all p values <.001), discriminant validity between smokers and nonsmokers (knowledge Cohen's drange: .57-.61, all p values <.001; attitude Cohen's drange: .78-.82, all p values <.001; behavior Cohen's drange: .90-.99, all p values <.001), and predictive validity (range R2KAB: .41-.48; all p values <.001). CONCLUSIONS: KAB scales about THS provide new opportunities for tobacco control advocates and scholars to identify gaps in knowledge, misperceptions, and obstacles to behavior change in order to guide the design of novel tobacco control policies and interventions. IMPLICATIONS: Numerous scales have been vetted as reliable and valid measures for assessing SHS-related KABs. Currently, standard measures of THS KABs are not available. This study tested three THS scales to fill this gap. The present findings provide tobacco control advocates, scholars, and practitioners tools for assessing KABs related to THS. This information is critical to development, implementation, and evaluation of novel tobacco control strategies.

Handwashing Results in Incomplete Nicotine Removal from Fingers of Individuals who Smoke: A Randomized Controlled Experiment.

OBJECTIVE: Tobacco residue, also known as third-hand smoke (THS), contains toxicants and lingers in dust and on surfaces and clothes. THS also remains on hands of individuals who smoke, with potential transfer to infants during visitation while infants are hospitalized in neonatal intensive care units (NICUs), raising concerns (e.g., hindered respiratory development) for vulnerable infants. Previously unexplored, this study tested handwashing (HW) and sanitization efficacy for finger-nicotine removal in a sample of adults who smoked and were visiting infants in an NICU. STUDY DESIGN: A cross-sectional sample was recruited to complete an interview, carbon monoxide breath samples, and three nicotine wipes of separate fingers (thumb, index, and middle). Eligible participants (n = 14) reported current smoking (verified with breath samples) and were randomly assigned to 30 seconds of HW (n = 7) or alcohol-based sanitization (n = 7), with the order of finger wipes both counterbalanced and randomly assigned. After randomization, the first finger was wiped for nicotine. Participants then washed or sanitized their hands and finger two was wiped 5 minutes later. An interview assessing tobacco/nicotine use and exposure was then administered, followed by a second breath sample and the final finger wipe (40-60 minutes after washing/sanitizing). RESULTS: Generalized linear mixed models found that HW was more effective than sanitizer for nicotine removal but failed to completely remove nicotine. CONCLUSIONS: Without proper protections (e.g., wearing gloves and gowns), NICU visitors who smoke may inadvertently expose infants to THS. Research on cleaning protocols are needed to protect vulnerable medical populations from THS and associated risks. KEY POINTS: · NICU infants may be exposed to THS via visitors.. · THS is not eliminated by HW or sanitizing.. · THS removal protections for NICU infants are needed..

Altered microbiomes in thirdhand smoke-exposed children and their home environments.

INTRODUCTION: Tobacco smoke contains numerous toxic chemicals that accumulate in indoor environments creating thirdhand smoke (THS). We investigated if THS-polluted homes differed in children's human and built-environment microbiomes as compared to THS-free homes. METHODS: Participants were n = 19 THS-exposed children and n = 10 unexposed children (≤5 years) and their caregivers. Environmental and biological samples were analyzed for THS pollutants and exposure. Swab samples were collected from the built-environment (floor, table, armrest, bed frame) and child (finger, nose, mouth, and ear canal), and 16S ribosomal RNA genes were analyzed for bacterial taxa using high-throughput DNA sequencing. RESULTS: Phylogenetic α-diversity was significantly higher for the built-environment microbiomes in THS-polluted homes compared to THS-free homes (p < 0.014). Log2-fold comparison found differences between THS-polluted and THS-free homes for specific genera in samples from the built-environment (e.g., Acinetobacter, Bradyrhizobium, Corynebacterium, Gemella, Neisseria, Staphylococcus, Streptococcus, and Veillonella) and in samples from children (esp. Corynebacterium, Gemella, Lautropia, Neisseria, Rothia, Staphylococcus, and Veillonella). CONCLUSION: When exposed to THS, indoor and children microbiomes are altered in an environment-specific manner. Changes are similar to those reported in previous studies for smokers and secondhand smoke-exposed persons. THS-induced changes in child and built-environmental microbiomes may play a role in clinical outcomes in children. IMPACT: Despite smoking bans, children can be exposed to tobacco smoke residue (i.e., thirdhand smoke) that lingers on surfaces and in settled house dust. Thirdhand smoke exposure is associated with changes in the microbiomes of the home environment and of the children living in these homes. Thirdhand smoke is associated with increased phylogenetic diversity of the home environment and changes in the abundances of several genera of the child microbiome known to be affected by active smoking and secondhand smoke (e.g., Corynebacterium, Staphylococcus, Streptococcus). Thirdhand smoke exposure by itself may induce alterations in the microbiome that play a role in childhood pathologies.

Thirdhand Smoke Contamination and Infant Nicotine Exposure in a Neonatal Intensive Care Unit: An Observational Study.

INTRODUCTION: Thirdhand smoke (THS) is ultrafine particulate matter and residue resulting from tobacco combustion, with implications for health-related harm (eg, impaired wound healing), particularly among hospitalized infants. Project aims were to characterize nicotine (THS proxy) transported on neonatal intensive care unit (NICU) visitors and deposited on bedside furniture, as well as infant exposure. METHODS: Cross-sectional data were collected from participants in a metropolitan NICU. Participants completed a survey and carbon monoxide breath sample, and 41.9% (n = 88) of participants (n = 210) were randomly selected for finger-nicotine wipes during a study phase when all bedside visitors were screened for nicotine use and finger-nicotine levels. During an overlapping study phase, 80 mother-infant dyads consented to bedside furniture-nicotine wipes and an infant urine sample (for cotinine analyses). RESULTS: Most nonstaff visitors' fingers had nicotine above the limit of quantification (>LOQ; 61.9%). Almost all bedside furniture surfaces (93.8%) and infant cotinine measures (93.6%) had values >LOQ, regardless of household nicotine use. Participants who reported using (or lived with others who used) nicotine had greater furniture-nicotine contamination (Mdn = 0.6 [interquartile range, IQR = 0.2-1.6] µg/m2) and higher infant cotinine (Mdn = 0.09 [IQR = 0.04-0.25] ng/mL) compared to participants who reported no household-member nicotine use (Mdn = 0.5 [IQR = 0.2-0.7] µg/m2; Mdn = 0.04 [IQR = 0.03-0.07] ng/mL, respectively). Bayesian univariate regressions supported hypotheses that increased nicotine use/exposure correlated with greater nicotine contamination (on fingers/furniture) and infant THS exposure. CONCLUSIONS: Potential furniture-contamination pathways and infant-exposure routes (eg, dermal) during NICU hospitalization were identified, despite hospital prohibitions on tobacco/nicotine use. This work highlights the surreptitious spread of nicotine and potential THS-related health risks to vulnerable infants during critical stages of development. IMPLICATIONS: THS contamination is underexplored in medical settings. Infants who were cared for in the NICU are vulnerable to health risks from THS exposure. This study demonstrated that 62% of nonstaff NICU visitors transport nicotine on their fingers to the NICU. Over 90% of NICU (bedside) furniture was contaminated with nicotine, regardless of visitors' reported household-member nicotine use or nonuse. Over 90% of infants had detectable levels of urinary cotinine during NICU hospitalizations. Results justify further research to better protect infants from unintended THS exposure while hospitalized.

Nicotine, Cotinine, and Tobacco-Specific Nitrosamines Measured in Children's Silicone Wristbands in Relation to Secondhand Smoke and E-cigarette Vapor Exposure.

INTRODUCTION: Simple silicone wristbands (WB) hold promise for exposure assessment in children. We previously reported strong correlations between nicotine in WB worn by children and urinary cotinine (UC). Here, we investigated differences in WB chemical concentrations among children exposed to secondhand smoke from conventional cigarettes (CC) or secondhand vapor from electronic cigarettes (EC), and children living with nonusers of either product (NS). METHODS: Children (n = 53) wore three WB and a passive nicotine air sampler for 7 days and one WB for 2 days, and gave a urine sample on day 7. Caregivers reported daily exposures during the 7-day period. We determined nicotine, cotinine, and tobacco-specific nitrosamines (TSNAs) concentrations in WB, nicotine in air samplers, and UC through isotope-dilution liquid chromatography with triple-quadrupole mass spectrometry. RESULTS: Nicotine and cotinine levels in WB in children differentiated between groups of children recruited into NS, EC exposed, and CC exposed groups in a similar manner to UC. WB levels were significantly higher in the CC group (WB nicotine median 233.8 ng/g silicone, UC median 3.6 ng/mL, n = 15) than the EC group (WB nicotine median: 28.9 ng/g, UC 0.5 ng/mL, n = 19), and both CC and EC group levels were higher than the NS group (WB nicotine median: 3.7 ng/g, UC 0.1 ng/mL, n = 19). TSNAs, including the known carcinogen NNK, were detected in 39% of WB. CONCLUSIONS: Silicone WB show promise for sensitive detection of exposure to tobacco-related contaminants from traditional and electronic cigarettes and have potential for tobacco control efforts. IMPLICATIONS: Silicone WB worn by children can absorb nicotine, cotinine, and tobacco-specific nitrosamines, and amounts of these compounds are closely related to the child's urinary cotinine. Levels of tobacco-specific compounds in the silicone WB can distinguish patterns of children's exposure to secondhand smoke and e-cigarette vapor. Silicone WB are simple to use and acceptable to children and, therefore, may be useful for tobacco control activities such as parental awareness and behavior change, and effects of smoke-free policy implementation.

Remediating Thirdhand Smoke Pollution in Multiunit Housing: Temporary Reductions and the Challenges of Persistent Reservoirs.

INTRODUCTION: Toxic tobacco smoke residue, also known as thirdhand smoke (THS), can persist in indoor environments long after tobacco has been smoked. This study examined the effects of different cleaning methods on nicotine in dust and on surfaces. AIMS AND METHODS: Participants had strict indoor home smoking bans and were randomly assigned to: dry/damp cleaning followed by wet cleaning 1 month later (N = 10), wet cleaning followed by dry/damp cleaning (N = 10) 1 month later, and dry/damp and wet cleaning applied the same day (N = 28). Nicotine on surfaces and in dust served as markers of THS and were measured before, immediately after, and 3 months after the cleaning, using liquid chromatography with triple quadrupole mass spectrometry (LC-MS/MS). RESULTS: Over a 4-month period prior to cleaning, surface nicotine levels remained unchanged (GeoMean change: -11% to +8%; repeated measures r = .94; p < .001). Used separately, dry/damp and wet cleaning methods showed limited benefits. When applied in combination, however, we observed significantly reduced nicotine on surfaces and in dust. Compared with baseline, GeoMean surface nicotine was 43% lower immediately after (z = -3.73, p < .001) and 53% lower 3 months later (z = -3.96, p < .001). GeoMean dust nicotine loading declined by 60% immediately after (z = -3.55, p < .001) and then increased 3 months later to precleaning levels (z = -1.18, p = .237). CONCLUSIONS: Cleaning interventions reduced but did not permanently remove nicotine in dust and on surfaces. Cleaning efforts for THS need to address persistent pollutant reservoirs and replenishment of reservoirs from new tobacco smoke intrusion. THS contamination in low-income homes may contribute to health disparities, particularly in children. IMPLICATIONS: Administered sequentially or simultaneously, the tested cleaning protocols reduced nicotine on surfaces by ~50% immediately after and 3 months after the cleaning. Nicotine dust loading was reduced by ~60% immediately after cleaning, but it then rebounded to precleaning levels 3 months later. Cleaning protocols were unable to completely remove THS, and pollutants in dust were replenished from remaining pollutant reservoirs or new secondhand smoke intrusion. To achieve better outcomes, cleaning protocols should be systematically repeated to remove newly accumulated pollutants. New secondhand smoke intrusions need to be prevented, and remaining THS reservoirs should be identified, cleaned, or removed to prevent pollutants from these reservoirs to accumulate in dust and on surfaces.

Differential associations of hand nicotine and urinary cotinine with children's exposure to tobacco smoke and clinical outcomes.

BACKGROUND: Children's overall tobacco smoke exposure (TSE) consists of both inhalation of secondhand smoke (SHS) and ingestion, dermal uptake, and inhalation of thirdhand smoke (THS) residue from dust and surfaces in their environments. OBJECTIVES: Our objective was to compare the different roles of urinary cotinine as a biomarker of recent overall TSE and hand nicotine as a marker of children's contact with nicotine pollution in their environments. We explored the differential associations of these markers with sociodemographics, parental smoking, child TSE, and clinical diagnoses. METHODS: Data were collected from 276 pediatric emergency department patients (Median age = 4.0 years) who lived with a cigarette smoker. Children's hand nicotine and urinary cotinine levels were determined using LC-MS/MS. Parents reported tobacco use and child TSE. Medical records were reviewed to assess discharge diagnoses. RESULTS: All children had detectable hand nicotine (GeoM = 89.7ng/wipe; 95 % CI = [78.9; 102.0]) and detectable urinary cotinine (GeoM = 10.4 ng/ml; 95%CI = [8.5; 12.6]). Although hand nicotine and urinary cotinine were highly correlated (r = 0.62, p < 0.001), urinary cotinine geometric means differed between racial groups and were higher for children with lower family income (p < 0.05), unlike hand nicotine. Independent of urinary cotinine, age, race, and ethnicity, children with higher hand nicotine levels were at increased risk to have discharge diagnoses of viral/other infectious illness (aOR = 7.49; 95%CI = [2.06; 27.24], p = 0.002), pulmonary illness (aOR = 6.56; 95%CI = [1.76; 24.43], p = 0.005), and bacterial infection (aOR = 5.45; 95%CI = [1.50; 19.85], p = 0.03). In contrast, urinary cotinine levels showed no associations with diagnosis independent of child hand nicotine levels and demographics. DISCUSSION: The distinct associations of hand nicotine and urinary cotinine suggest the two markers reflect different exposure profiles that contribute differentially to pediatric illness. Because THS in a child's environment directly contributes to hand nicotine, additional studies of children of smokers and nonsmokers are warranted to determine the role of hand nicotine as a marker of THS exposure and its potential role in the development of tobacco-related pediatric illnesses.

Thirdhand smoke associations with the gut microbiomes of infants admitted to a neonatal intensive care unit: An observational study.

INTRODUCTION: Microbiome differences have been found in adults who smoke cigarettes compared to non-smoking adults, but the impact of thirdhand smoke (THS; post-combustion tobacco residue) on hospitalized infants' rapidly developing gut microbiomes is unexplored. Our aim was to explore gut microbiome differences in infants admitted to a neonatal ICU (NICU) with varying THS-related exposure. METHODS: Forty-three mother-infant dyads (household member[s] smoke cigarettes, n = 32; no household smoking, n = 11) consented to a carbon monoxide-breath sample, bedside furniture nicotine wipes, infant-urine samples (for cotinine [nicotine's primary metabolite] assays), and stool collection (for 16S rRNA V4 gene sequencing). Negative binomial regression modeled relative abundances of 8 bacterial genera with THS exposure-related variables (i.e., household cigarette use, surface nicotine, and infant urine cotinine), controlling for gestational age, postnatal age, antibiotic use, and breastmilk feeding. Microbiome-diversity outcomes were modeled similarly. Bayesian posterior probabilities (PP) ≥75.0% were considered meaningful. RESULTS: A majority of infants (78%) were born pre-term. Infants from non-smoking homes and/or with lower NICU-furniture surface nicotine had greater microbiome alpha-diversity compared to infants from smoking households (PP ≥ 75.0%). Associations (with PP ≥ 75.0%) of selected bacterial genera with urine cotinine, surface nicotine, and/or household cigarette use were evidenced for 7 (of 8) modeled genera. For example, lower Bifidobacterium relative abundance associated with greater furniture nicotine (IRR<0.01 [<0.01, 64.02]; PP = 87.1%), urine cotinine (IRR = 0.08 [<0.01,2.84]; PP = 86.9%), and household smoking (IRR<0.01 [<0.01, 7.38]; PP = 96.0%; FDR p < 0.05). CONCLUSIONS: THS-related exposure was associated with microbiome differences in NICU-admitted infants. Additional research on effects of tobacco-related exposures on healthy infant gut-microbiome development is warranted.

Randomised controlled trial of real-time feedback and brief coaching to reduce indoor smoking.

BACKGROUND: Previous secondhand smoke (SHS) reduction interventions have provided only delayed feedback on reported smoking behaviour, such as coaching, or presenting results from child cotinine assays or air particle counters. DESIGN: This SHS reduction trial assigned families at random to brief coaching and continuous real-time feedback (intervention) or measurement-only (control) groups. PARTICIPANTS: We enrolled 298 families with a resident tobacco smoker and a child under age 14. INTERVENTION: We installed air particle monitors in all homes. For the intervention homes, immediate light and sound feedback was contingent on elevated indoor particle levels, and up to four coaching sessions used prompts and praise contingent on smoking outdoors. Mean intervention duration was 64 days. MEASURES: The primary outcome was 'particle events' (PEs) which were patterns of air particle concentrations indicative of the occurrence of particle-generating behaviours such as smoking cigarettes or burning candles. Other measures included indoor air nicotine concentrations and participant reports of particle-generating behaviour. RESULTS: PEs were significantly correlated with air nicotine levels (r=0.60) and reported indoor cigarette smoking (r=0.51). Interrupted time-series analyses showed an immediate intervention effect, with reduced PEs the day following intervention initiation. The trajectory of daily PEs over the intervention period declined significantly faster in intervention homes than in control homes. Pretest to post-test, air nicotine levels, cigarette smoking and e-cigarette use decreased more in intervention homes than in control homes. CONCLUSIONS: Results suggest that real-time particle feedback and coaching contingencies reduced PEs generated by cigarette smoking and other sources. TRIAL REGISTRATION NUMBER: NCT01634334; Post-results.

A framework for measurement and harmonization of pediatric multiple sclerosis etiologic research studies: The Pediatric MS Tool-Kit.

BACKGROUND: While studying the etiology of multiple sclerosis (MS) in children has several methodological advantages over studying etiology in adults, studies are limited by small sample sizes. OBJECTIVE: Using a rigorous methodological process, we developed the Pediatric MS Tool-Kit, a measurement framework that includes a minimal set of core variables to assess etiological risk factors. METHODS: We solicited input from the International Pediatric MS Study Group to select three risk factors: environmental tobacco smoke (ETS) exposure, sun exposure, and vitamin D intake. To develop the Tool-Kit, we used a Delphi study involving a working group of epidemiologists, neurologists, and content experts from North America and Europe. RESULTS: The Tool-Kit includes six core variables to measure ETS, six to measure sun exposure, and six to measure vitamin D intake. The Tool-Kit can be accessed online ( www.maelstrom-research.org/mica/network/tool-kit ). CONCLUSION: The goals of the Tool-Kit are to enhance exposure measurement in newly designed pediatric MS studies and comparability of results across studies, and in the longer term to facilitate harmonization of studies, a methodological approach that can be used to circumvent issues of small sample sizes. We believe the Tool-Kit will prove to be a valuable resource to guide pediatric MS researchers in developing study-specific questionnaire.

Cotton pillows: A novel field method for assessment of thirdhand smoke pollution.

Thirdhand smoke (THS) is the residue left behind by secondhand smoke (SHS) that accumulates in indoor environments. THS chemicals can persist long after smoking has ceased and can re-emit semivolatile compounds back into the air. Measuring tobacco smoke pollution in real-world field setting can be technically complex, expensive, and intrusive. This study placed pillows in homes of former smokers and examined how much nicotine adsorbed to them over a three-week period. Organic cotton pillows were placed in the homes of 8 former smokers following the first week after verified smoking cessation until the fourth week. For comparison, pillows were also placed in 4 homes of nonsmokers. Nicotine concentrations were determined in the pillow case, fabric, and cotton filling, using isotope-dilution liquid chromatography tandem mass spectrometry. Cotton pillows placed in homes of former smokers absorbed on average 21.5 µg of nicotine. Nicotine concentration per gram of material significantly differed between pillow components (p < 0.001) and was highest for the pillow case (257 ng/g), followed by the pillow fabric (97 ng/g), and the pillow filling (17 ng/g). Nicotine levels in pillows placed in nonsmokers' homes did not differ from laboratory blanks (p > 0.40), or between pillow components (p > 0.40). In the absence of any smoking activity, cotton pillows absorbed significant amounts of nicotine emitted from THS reservoirs in the homes of former smokers. Given the much higher concentrations of SHS in the homes of active smokers, fabrics found throughout the home of a smoker are likely to store a substantial mass of tobacco smoke toxicants. Cotton pillows present a novel method that could be of interest to researchers requiring robust and unobtrusive methods to examine tobacco smoke pollution in real-world field settings.

Contribution of thirdhand smoke to overall tobacco smoke exposure in pediatric patients: study protocol.

BACKGROUND: Thirdhand smoke (THS) is the persistent residue resulting from secondhand smoke (SHS) that accumulates in dust, objects, and on surfaces in homes where tobacco has been used, and is reemitted into air. Very little is known about the extent to which THS contributes to children's overall tobacco smoke exposure (OTS) levels, defined as their combined THS and SHS exposure. Even less is known about the effect of OTS and THS on children's health. This project will examine how different home smoking behaviors contribute to THS and OTS and if levels of THS are associated with respiratory illnesses in nonsmoking children. METHODS: This project leverages the experimental design from an ongoing pediatric emergency department-based tobacco cessation trial of caregivers who smoke and their children (NIHR01HD083354). At baseline and follow-up, we will collect urine and handwipe samples from children and samples of dust and air from the homes of smokers who smoke indoors, have smoking bans or who have quit smoking. These samples will be analyzed to examine to what extent THS pollution at home contributes to OTS exposure over and above SHS and to what extent THS continues to persist and contribute to OTS in homes of smokers who have quit or have smoking bans. Targeted and nontargeted chemical analyses of home dust samples will explore which types of THS pollutants are present in homes. Electronic medical record review will examine if THS and OTS levels are associated with child respiratory illness. Additionally, a repository of child and environmental samples will be created. DISCUSSION: The results of this study will be crucial to help close gaps in our understanding of the types, quantity, and clinical effects of OTS, THS exposure, and THS pollutants in a unique sample of tobacco smoke-exposed ill children and their homes. The potential impact of these findings is substantial, as currently the level of risk in OTS attributable to THS is unknown. This research has the potential to change how we protect children from OTS, by recognizing that SHS and THS exposure needs to be addressed separately and jointly as sources of pollution and exposure. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02531594 . Date of registration: August 24, 2015.

Serum Cotinine and Hemoglobin A1c Among a National Sample of Adolescents Without Known Diabetes.

Introduction: National data suggest tobacco smoke is positively associated with higher glycated hemoglobin (HbA1c) among adults. Our objective was to examine the association between serum cotinine and HbA1c among adolescents without known diabetes. Methods: We assessed adolescents 12-19 years old (N = 11550) who participated in the 1999-2012 National Health and Nutrition Examination Survey. We applied sampling weights while performing multiple linear regression analyses. Results: The prevalence of serum cotinine indicative of no tobacco smoke exposure (TSE, <0.05 ng/mL) was 43.2%, passive TSE (0.05-2.99 ng/mL) was 38.9%, and active TSE (>3 ng/mL) was 17.9% in our sample. Mean (± standard error) HbA1c in participants with no TSE was 5.16% (±0.01), passive TSE was 5.16% (±0.01), and active TSE was 5.14% (±0.01). No differences in HbA1c were found between TSE groups including sex, age, race/ethnicity, education, income, and physical activity or the fully adjusted model with waist circumference. We found cotinine × sex (p = .01) and cotinine × age (p = .02) interactions. There was an association between cotinine and HbA1c for males but not females. Within males, participants with cotinine ≥3 ng/mL (5.26 ± 0.02) had higher mean HbA1c than those with cotinine 0.05-2.99 ng/mL and <0.05 ng/mL (both 5.20 ± 0.01, p ≤ .02). The negative association between age and HbA1c was stronger for participants with cotinine ≥3 ng/mL than participants with cotinine <0.05 ng/mL. Conclusion: No linear association was found between HbA1c and serum cotinine in adolescents overall after adjusting for potential confounders. Differences between TSE groups were found in males. Future research in adolescents should examine chronic TSE over time to examine the potential for development of type 2 diabetes. Implications: TSE has been associated with increased risk for the development of type 2 diabetes among adults. It is unclear if this relationship holds in adolescents. We examined the association between serum cotinine and HbA1c in adolescents without known diabetes who completed the 1999-2012 National Health and Nutrition Examination Survey. Although no association was found between serum cotinine and HbA1c overall while controlling for potential confounding factors, we observed interaction effects that are indicative of TSE influencing HbA1c differentially by sex and age. Reducing TSE in adolescents should be a priority for future tobacco control efforts.

Preliminary evidence that high levels of nicotine on children's hands may contribute to overall tobacco smoke exposure.

BACKGROUND: Dust and surfaces are important sources of lead and pesticide exposure in young children. The purpose of this pilot study was to investigate if third-hand smoke (THS) pollutants accumulate on the hands of children who live in environments where tobacco is used and if hand nicotine levels are associated with second-hand smoke (SHS), as measured by salivary cotinine. METHODS: Participants were parents and children (n=25; age mean (SD)=5.4 (5.3) years) presenting to the emergency department with a potentially SHS-related illness. A convenience sample of participants were recruited at baseline from an ongoing two-group, randomised controlled trial of a SHS reduction and tobacco cessation intervention. Parents were current smokers; thus, all children were at risk of SHS and THS exposure to varying extents. Primary outcome measures, which were assessed in child participants only, were hand nicotine and salivary cotinine. Parents reported sociodemographics and smoking patterns; children's medical records were abstracted for chief complaint, medical history and discharge diagnosis. RESULTS: All children had detectable hand nicotine (range=18.3-690.9 ng/wipe). All but one had detectable cotinine (range=1.2-28.8 ng/mL). Multiple linear regression results showed a significant positive association between hand nicotine and cotinine (p=0.009; semipartial r2=0.24), independent of child age. DISCUSSION: The higher-than-expected nicotine levels and significant association with cotinine indicate that THS may play a role in the overall exposure of young children to tobacco smoke toxicants and that hand wipes could be a useful marker of overall tobacco smoke pollution and a proxy for exposure. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov Identifier: NCT02531594.