Two decades of nonfatal injury data: a scoping review of the National Electronic Injury Surveillance System-All Injury Program, 2001-2021.

BACKGROUND: Injury is a leading cause of preventable morbidity and mortality in the USA. Ongoing surveillance is needed to understand changing injury patterns to effectively target prevention efforts. Launched jointly in 2000 by the Consumer Product Safety Commission (CPSC) and the Centers for Disease Control and Prevention (CDC), the National Electronic Injury Surveillance System-All Injury Program (NEISS-AIP) provides national-level estimates of US emergency department visits for nonfatal injuries. A scoping review of peer-reviewed articles was conducted to characterize how NEISS-AIP data have been used for injury surveillance in the USA. MAIN BODY: This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Three bibliographic databases (PubMed, Scopus, and Google Scholar) were systematically searched for English language peer-reviewed articles that used NEISS-AIP data as the primary data source during 2001-2021. Key article characteristics from included articles were abstracted to generate descriptive summary statistics to understand the use and limitations of NEISS-AIP for injury surveillance. Database queries returned 6944 citations; 594 citations were manually reviewed, and 167 non-duplicate journal articles were identified. An average of 8.0 articles (range: 1-14) were published annually during 2001-2021. Articles appeared in 72 different journals representing a diverse audience with the majority of articles written by CDC authors. Starting in 2013, a higher proportion of articles were published by non-CDC authors. The largest number of articles examined injury among all age groups (n = 71); however, the pediatric population was the specific age group of greatest interest (n = 48), followed by older adults (n = 23). Falls (n = 20) and motor-vehicle-related injuries (n = 10) were the most studied injury mechanisms. The most commonly identified limitation identified by authors of reviewed articles was that NEISS-AIP only produces national estimates and therefore, cannot be used for state- or county-level injury surveillance (n = 38). CONCLUSIONS: NEISS-AIP has contributed to nonfatal injury surveillance in the USA. CDC and CPSC continue to work together to expand and enhance NEISS-AIP data collection. Researchers are encouraged to continue using this publicly available dataset for injury surveillance.

Emergency Department Visits for Alcohol-Associated Falls Among Older Adults in the United States, 2011 to 2020.

STUDY OBJECTIVE: The aim of this study was to examine the epidemiology of alcohol-associated fall injuries among older adults aged ≥65 years in the United States. METHODS: We included emergency department (ED) visits for unintentional fall injuries by adults from the National Electronic Injury Surveillance System-All Injury Program during 2011 to 2020. We estimated the annual national rate of ED visits for alcohol-associated falls and the proportion of these falls among older adults' fall-related ED visits using demographic and clinical characteristics. Joinpoint regression was performed to examine trends in alcohol-associated ED fall visits between 2011 and 2019 among older adult age subgroups and to compare these trends with those of younger adults. RESULTS: There were 9,657 (weighted national estimate: 618,099) ED visits for alcohol-associated falls, representing 2.2% of ED fall visits during 2011 to 2020 among older adults. The proportion of fall-related ED visits that were alcohol-associated was higher among men than among women (adjusted prevalence ratio [aPR]=3.6, 95% confidence interval [CI] 2.9 to 4.5). The head and face were the most commonly injured body parts, and internal injury was the most common diagnosis for alcohol-associated falls. From 2011 to 2019, the annual rate of ED visits for alcohol-associated falls increased (annual percent change 7.5, 95% CI 6.1 to 8.9) among older adults. Adults aged 55 to 64 years had a similar increase; a sustained increase was not detected in younger age groups. CONCLUSION: Our findings highlight the rising rates of ED visits for alcohol-associated falls among older adults during the study period. Health care providers in the ED can screen older adults for fall risk and assess for modifiable risk factors such as alcohol use to help identify those who could benefit from interventions to reduce their risk.

Emergency Department Visits by Incarcerated Adults for Nonfatal Injuries - United States, 2010-2019.

During 2010-2019, U.S. correctional authorities held 1.4-1.6 million persons in state and federal prisons annually, and 10.3-12.9 million persons were admitted to local jails each year (1,2). Incarcerated persons experience a disproportionate burden of negative health outcomes, including unintentional and violence-related injuries (3,4). No national studies on injury-related emergency department (ED) visits by incarcerated persons have been conducted, but a previous study demonstrated a high rate of such visits among a Seattle, Washington jail population (5). To examine nonfatal injury-related ED visits among incarcerated adults, CDC analyzed 2010-2019 National Electronic Injury Surveillance System-All Injury Program (NEISS-AIP) data. During 2010-2019, an estimated 733,547 ED visits by incarcerated adults occurred in the United States. The proportion of ED visits resulting from assault* and self-harm among incarcerated adults was five times as high as those among nonincarcerated adults. Among incarcerated adults, men and adult persons aged <65 years had the highest proportion of assault-related ED visits. Falls accounted for the most ED visits among incarcerated adults aged ≥65 years. A higher proportion of ED visits by incarcerated women than incarcerated men were for overdose or poisoning. These findings suggest that injuries among incarcerated adults differ from those among nonincarcerated adults and might require development and implementation of age- and sex-specific prevention strategies for this population.

Characteristics of Persons Who Report Using Only Nicotine-Containing Products Among Interviewed Patients with E-cigarette, or Vaping, Product Use-Associated Lung Injury - Illinois, August-December 2019.

In 2019, the United States experienced an outbreak of e-cigarette, or vaping, product use-associated lung injury (EVALI) (1). Most EVALI patients have reported using tetrahydrocannabinol (THC)-containing e-cigarette, or vaping, products obtained from informal sources (2,3), and vitamin E acetate in these products has been closely linked with EVALI (4,5). However, some EVALI patients report using only nicotine-containing products. This study compared demographic, product use, and clinical characteristics of EVALI patients in Illinois who reported using only nicotine-containing e-cigarette, or vaping, products with those of patients who reported using any THC-containing products. Among 121 interviewed Illinois EVALI patients, 17 (14%) reported using only nicotine-containing products, including nine (7%) patients who had no indication of any THC use, based on self-report or toxicology testing. Compared with patients who used any THC-containing products, these nine patients were significantly more likely to be older and female and were less likely to experience constitutional symptoms or to have leukocytosis on initial evaluation. Although vitamin E acetate has been strongly linked with EVALI, evidence is not sufficient to rule out the contribution of other chemicals of concern, including chemicals in either THC- or non-THC-containing products, in some reported EVALI cases. The contributing cause or causes of EVALI for patients reporting use of only nicotine-containing products warrants further investigation.

Pulmonary Illness Related to E-Cigarette Use in Illinois and Wisconsin - Final Report.

BACKGROUND: E-cigarettes are battery-operated devices that heat a liquid and deliver an aerosolized product to the user. Pulmonary illnesses related to e-cigarette use have been reported, but no large series has been described. In July 2019, the Wisconsin Department of Health Services and the Illinois Department of Public Health received reports of lung injury associated with the use of e-cigarettes (also called vaping) and launched a coordinated public health investigation. METHODS: We defined case patients as persons who reported use of e-cigarette devices and related products in the 90 days before symptom onset and had pulmonary infiltrates on imaging and whose illnesses were not attributed to other causes. Medical record abstraction and case patient interviews were conducted with the use of standardized tools. RESULTS: There were 98 case patients, 79% of whom were male; the median age of the patients was 21 years. The majority of patients presented with respiratory symptoms (97%), gastrointestinal symptoms (77%), and constitutional symptoms (100%). All case patients had bilateral infiltrates on chest imaging. A total of 95% of the patients were hospitalized, 26% underwent intubation and mechanical ventilation, and two deaths were reported. A total of 89% of the patients reported having used tetrahydrocannabinol products in e-cigarette devices, although a wide variety of products and devices was reported. Syndromic surveillance data from Illinois showed that the mean monthly rate of visits related to severe respiratory illness in June through August of 2019 was twice the rate that was observed in the same months in 2018. CONCLUSIONS: Case patients presented with similar clinical characteristics. Although the definitive substance or substances contributing to injury have not been determined, this initial cluster of illnesses represents an emerging clinical syndrome or syndromes. Additional work is needed to characterize the pathophysiology and to identify the definitive causes.

The Public Health Response to a Large Poisoning Outbreak Involving an Illicit Substance: Synthetic Cannabinoids Contaminated With a Long-Acting Anticoagulant Rodenticide, Illinois, March-July, 2018.

During March-July 2018, the Illinois Department of Public Health responded to an acute outbreak of severe coagulopathy among patients with recent synthetic cannabinoid use. Toxicological testing indicated that cases were exposed to brodifacoum, a long-acting anticoagulant rodenticide. A total of 174 confirmed and probable cases, including 5 deaths, were linked to this outbreak. On the basis of the experience of responding to this complex outbreak, we recommend several steps for consideration to improve health department preparation for acute outbreaks involving illicit substances including strengthening communication between public health and law enforcement agencies, reviewing legal authority to investigate noninfectious acute disease outbreaks, continuing strong partnerships with state poison control centers, partnering with substance abuse and mental health agencies to provide services to patients, and determining health department ability to rapidly enter into public-private partnership agreements.

An outbreak of severe coagulopathy from synthetic cannabinoids tainted with Long-Acting anticoagulant rodenticides.

Objective: To describe a large regional poison center's experience managing an outbreak of long-acting anticoagulant rodenticide (LAAR) poisoning associated with synthetic cannabinoid (SC) use.Methods: This is a retrospective review of exposures reported to the Illinois Poison Center between March 10 and August 1, 2018. All cases coded as exposure to Δ9-tetrahydrocannabinol homologs were identified. Patients with suspected SC use, positive LAAR testing, and coagulopathy (signs or symptoms of bleeding or international normalized ratio [INR] > 2) were included. If confirmatory LAAR testing was performed and resulted as negative, the patient was excluded from this analysis. In the absence of LAAR testing, patients with suspected SC use, an INR >2, and no alternative explanation of coagulopathy were included. Suspected SC use was defined as use suspected by a member of the treating team or reported by the patient. Presenting signs and symptoms, laboratory findings, management, healthcare utilization, outcomes, and disposition of patients affected by this outbreak were reported.Results: One hundred seventy-eight cases met inclusion criteria. Most patients were male (73%) and young to middle-aged (median age 32, IQR 25-40). Most presented to hospitals in Peoria (35%) and Cook (31%) counties. Median hospitalization was three days (IQR 2-4). Eighty-eight percent of patients presented with an INR >10. Eighteen cases had qualitative anticoagulant testing, all of which were positive for brodifacoum. Other identified LAARs included difenacoum (10/18) and bromadiolone (1/18). Sixty-three percent of patients had back, flank or abdominal pain; 70% of patients presented with hematuria. One hundred six cases received IV vitamin K1; no adverse or anaphylactoid reactions were reported. Forty-one (22%) patients left AMA. Thirty-eight patients (21%) were re-hospitalized during the study period. Patients leaving AMA were 1.6 times more likely to be re-hospitalized than patients with other dispositions. Intracranial hemorrhage, present in 3% of total cases, was present in 4 of 5 fatalities.Conclusions: We describe an outbreak of multiple LAARs contaminating SCs. Patients presented with bleeding from varied sites, often required blood products, factor replacement, and high dose vitamin K1 for stabilization.

Risk Factors for E-Cigarette, or Vaping, Product Use-Associated Lung Injury (EVALI) Among Adults Who Use E-Cigarette, or Vaping, Products - Illinois, July-October 2019.

The United States is experiencing an unprecedented outbreak of e-cigarette, or vaping, product use-associated lung injury (EVALI) (1). All EVALI patients have used e-cigarette, or vaping, products, and most (≥85%) have reported using products containing tetrahydrocannabinol (THC) (2,3), the principal psychoactive component of cannabis. To examine whether e-cigarette, or vaping, product use behaviors differed between adult EVALI patients and adults who use these products but have not developed lung injury, the Illinois Department of Public Health (IDPH) conducted an online public survey during September-October 2019 targeting e-cigarette, or vaping, product users in Illinois. Among 4,631 survey respondents, 94% reported using any nicotine-containing e-cigarette, or vaping, products in the past 3 months; 21% used any THC-containing products; and 11% used both THC-containing products and nicotine-containing products. Prevalence of THC-containing product use was highest among survey respondents aged 18-24 years (36%) and decreased with increasing age. E-cigarette, or vaping, product use behaviors of 66 EVALI patients aged 18-44 years who were interviewed as part of the ongoing outbreak investigation were compared with a subset of 519 survey respondents aged 18-44 years who reported use of THC-containing e-cigarette, or vaping, products. Compared with these survey respondents, EVALI patients had higher odds of reporting exclusive use of THC-containing products (adjusted odds ratio [aOR] = 2.0, 95% confidence interval [CI] = 1.1-3.6); frequent use (more than five times per day) of these products (aOR = 3.1, 95% CI = 1.6-6.0), and obtaining these products from informal sources, such as a dealer, off the street, or from a friend (aOR = 9.2, 95% CI = 2.2-39.4). The odds of using Dank Vapes, a class of largely counterfeit THC-containing products, was also higher among EVALI patients (aOR = 8.5, 95% CI = 3.8-19.0). These findings reinforce current recommendations not to use e-cigarette, or vaping, products that contain THC and not to use any e-cigarette, or vaping, products obtained from informal sources. In addition, because the specific compound or ingredient causing lung injury is not yet known, CDC continues to recommend that persons consider refraining from use of all e-cigarette, or vaping, products while the outbreak investigation continues (1).

E-cigarette Product Use, or Vaping, Among Persons with Associated Lung Injury - Illinois and Wisconsin, April-September 2019.

In July 2019, the Illinois Department of Public Health and the Wisconsin Department of Health Services launched a coordinated epidemiologic investigation after receiving reports of several cases of lung injury in previously healthy persons who reported electronic cigarette (e-cigarette) use, or vaping (1). This report describes features of e-cigarette product use by patients in Illinois and Wisconsin. Detailed patient interviews were conducted by telephone, in person, or via the Internet with 86 (68%) of 127 patients. Overall, 75 (87%) of 86 interviewed patients reported using e-cigarette products containing tetrahydrocannabinol (THC), and 61 (71%) reported using nicotine-containing products. Numerous products and brand names were identified by patients. Nearly all (96%) THC-containing products reported were packaged, prefilled cartridges, and 89% were primarily acquired from informal sources (e.g., friends, family members, illicit dealers, or off the street). In contrast, 77% of nicotine-containing products were sold as prefilled cartridges, and 83% were obtained from commercial vendors. The precise source of this outbreak is currently unknown (2); however, the predominant use of prefilled THC-containing cartridges among patients with lung injury associated with e-cigarette use suggests that they play an important role. While this investigation is ongoing, CDC recommends that persons consider refraining from using e-cigarette, or vaping, products, particularly those containing THC. Given the diversity of products reported and frequency of patients using both THC- and nicotine-containing e-cigarette products, additional methods such as product testing and traceback could help identify the specific cause of this outbreak.

Identifying Areas with Disproportionate Local Health Department Services Relative to Opioid Overdose, HIV and Hepatitis C Diagnosis Rates: A Study of Rural Illinois.

Background: U.S. rural populations have been disproportionately affected by the syndemic of opioid-use disorder (OUD) and the associated increase in overdoses and risk of hepatitis C virus (HCV) and human immunodeficiency virus (HIV) transmission. Local health departments (LHDs) can play a critical role in the response to this syndemic. We utilized two geospatial approaches to identify areas of discordance between LHD service availability and disease burden to inform service prioritization in rural settings. Methods: We surveyed rural Illinois LHDs to assess their OUD-related services, and calculated county-level opioid overdose, HIV, and hepatitis C diagnosis rates. Bivariate choropleth maps were created to display LHD service provision relative to disease burden in rural Illinois counties. Results: Most rural LHDs provided limited OUD-related services, although many LHDs provided HIV and HCV testing. Bivariate mapping showed rural counties with limited OUD treatment and HIV services and with corresponding higher outcome/disease rates to be dispersed throughout Illinois. Additionally, rural counties with limited LHD-offered hepatitis C services and high hepatitis C diagnosis rates were geographically concentrated in southern Illinois. Conclusions: Bivariate mapping can enable geographic targeting of resources to address the opioid crisis and related infectious disease by identifying areas with low LHD services relative to high disease burden.

Hospitalization Trends and Comorbidities Among People With HIV/AIDS Compared With the Overall Hospitalized Population, Illinois, 2008-2014.

OBJECTIVES: To understand trends in health care use among people living with HIV/AIDS (PLWHA), this study compared trends in hospitalization rates, comorbidities, and hospital death rates of hospitalized PLWHA with the overall hospitalized population in Illinois during 2008-2014. METHODS: This study identified principal hospitalizations (the principal discharge diagnosis coded with an HIV-related billing code) and secondary HIV hospitalizations (a non-principal discharge diagnosis coded with an HIV-related billing code) from 2008-2014 Illinois hospital discharge data. Hospitalization rates among PLWHA were calculated using prevalence data from the Illinois Electronic HIV/AIDS Registry; US Census population estimates were used to calculate overall Illinois hospitalization rates. Joinpoint regression analysis was used to assess trends overall and among demographic subgroups. Comorbidities and discharge status for all hospitalizations were identified. RESULTS: In 2014, the hospitalization rate was 2.2 times higher among PLWHA than among the overall Illinois hospitalized population. From 2008 to 2014, principal HIV hospitalization rates per 1000 PLWHA decreased by 48% (from 71 to 37) and secondary HIV hospitalization rates declined by 26% (from 296 to 218). The decline in the principal HIV hospitalization rate was steepest from 2008 to 2011 (annual percentage change = -16.0%; P = .003). Mood disorders, substance-related diagnoses, and schizophrenia accounted for 18% to 22% of principal hospitalizations among PLWHA compared with 7% to 8% of overall Illinois hospitalizations. Hepatitis as a comorbidity was more common among hospitalized PLWHA (18%-22%) than among the overall Illinois hospitalized population (1.4%-1.5%). Hospitalized PLWHA were 3 times more likely than the overall Illinois hospitalized population to die while hospitalized. CONCLUSIONS: HIV hospitalizations are largely preventable with appropriate treatment and adherence. Additional efforts to improve retention in HIV care that address comorbidities of PLWHA are needed.

Hospitalizations for heat-stress illness varies between rural and urban areas: an analysis of Illinois data, 1987-2014.

BACKGROUND: The disease burden due to heat-stress illness (HSI), which can result in significant morbidity and mortality, is expected to increase as the climate continues to warm. In the United States (U.S.) much of what is known about HSI epidemiology is from analyses of urban heat waves. There is limited research addressing whether HSI hospitalization risk varies between urban and rural areas, nor is much known about additional diagnoses of patients hospitalized for HSI. METHODS: Hospitalizations in Illinois for HSI (ICD-9-CM codes 992.x or E900) in the months of May through September from 1987 to 2014 (n = 8667) were examined. Age-adjusted mean monthly hospitalization rates were calculated for each county using U.S. Census population data. Counties were categorized into five urban-rural strata using Rural Urban Continuum Codes (RUCC) (RUCC1, most urbanized to RUCC5, thinly populated). Average maximum monthly temperature (°C) was calculated for each county using daily data. Multi-level linear regression models were used, with county as the fixed effect and temperature as random effect, to model monthly hospitalization rates, adjusting for the percent of county population below the poverty line, percent of population that is Non-Hispanic Black, and percent of the population that is Hispanic. All analyses were stratified by county RUCC. Additional diagnoses of patients hospitalized for HSI and charges for hospitalization were summarized. RESULTS: Highest rates of HSI hospitalizations were seen in the most rural, thinly populated stratum (mean annual summer hospitalization rate of 1.16 hospitalizations per 100,000 population in the thinly populated strata vs. 0.45 per 100,000 in the metropolitan urban strata). A one-degree Celsius increase in maximum monthly average temperature was associated with a 0.34 increase in HSI hospitalization rate per 100,000 population in the thinly populated counties compared with 0.02 per 100,000 in highly urbanized counties. The most common additional diagnoses of patients hospitalized with HSI were dehydration, electrolyte abnormalities, and acute renal disorders. Total and mean hospital charges for HSI cases were $167.7 million and $20,500 (in 2014 US dollars). CONCLUSION: Elevated temperatures appear to have different impacts on HSI hospitalization rates as function of urbanization. The most rural and the most urbanized counties of Illinois had the largest increases in monthly hospitalization rates for HSI per unit increase in the average monthly maximum temperature. This suggests that vulnerability of communities to heat is complex and strategies to reduce HSI may need to be tailored to the degree of urbanization of a county.

Childhood asthma surveillance by community coalitions.

Multiple benefits can accrue when community coalitions conduct asthma surveillance activities. Surveillance data are used to identify children with asthma, assess disease burden and needs in the community, understand the illness and risk factors, identify children with asthma who are undertreated, plan community interventions, evaluate the effect of interventions, and monitor trends. These data, which are used to inform coalition and program decisions and to evaluate asthma interventions, can also be used to strengthen state and national asthma surveillance efforts and to inform clinical practice and public health policies. Local coalition data collection represents a complementary approach to national asthma surveillance, allowing action at the local level and showing how local findings vary from national observations. The Allies Against Asthma coalitions developed several practical means to conduct childhood asthma surveillance that informed coalition efforts and facilitated innovative linkages among government officials, health care providers, community agencies, families, and academicians and/or researchers.

Asthma and tobacco: double trouble for Wisconsin adolescents.

BACKGROUND: Environmental tobacco smoke (ETS) exposure has been identified as a cause of asthma and a trigger of asthma attacks in children. We examined the relation of demographic and tobacco-related risk factors to both lifetime asthma diagnosis and the asthma attack rate among Wisconsin adolescents. The impact of asthma on adolescent school absenteeism was also examined. METHODS: Data used were from the 2004 Wisconsin Youth Tobacco Survey (n=3125), which was administered in a sample of Wisconsin public middle and high schools. Multivariable logistic regression was used to examine risk factors simultaneously. RESULTS: Self-reported lifetime asthma prevalence was 19% among Wisconsin adolescents. Thirty-five percent of adolescents with asthma reported having an asthma attack in the past 12 months. Living with a smoker was a significant predictor of lifetime asthma diagnosis and, among adolescents with asthma, daily ETS exposure was associated with a 2-fold increased risk of having an asthma attack. Being diagnosed with asthma did not deter adolescents from smoking and was a significant predictor of school absenteeism. CONCLUSIONS: Asthma is an important health problem for Wisconsin adolescents. Tobacco-related risk factors contribute to the burden of the disease. Interventions to reduce smoking and ETS exposure targeted to adolescents and their guardians are needed. Better asthma control among adolescents could reduce school absenteeism.

Asthma in Wisconsin adults: a persistent problem for patients and providers.

Asthma is a chronic lung condition that requires active provider and patient management to prevent chronic symptoms and exacerbations. Data from the 2002 Wisconsin Behavioral Risk Factor Survey were used to determine asthma prevalence and characterize asthma symptom severity, control, and management among Wisconsin adults. About 8.5% or an estimated 345,000 adults in Wisconsin reported currently having asthma. Most adults with asthma (66%) have symptoms consistent with intermittent asthma. Over 80% of Wisconsin adults with asthma reported experiencing asthma symptoms in the past 30 days and 14% reported going to the emergency department for asthma in the past 12 months. The National Asthma Education and Prevention Program Management and Diagnosis Guidelines are considered the standard of quality for asthma care. Asthma management in Wisconsin falls short of meeting these guidelines. Classifying the severity of asthma, scheduling routine follow-up care, recommending measures to control asthma triggers, and treating or preventing comorbid conditions are key asthma management clinical activities. Increased clinical management coupled with improved patient self-management is needed to reduce the burden of asthma in Wisconsin. The Wisconsin Asthma Plan, released by the Wisconsin Asthma Coalition, provides concrete steps for improving provider and patient asthma management.

Relationship of serum antioxidants to asthma prevalence in youth.

The relationship of serum vitamin E, beta-carotene, vitamin C, and selenium to asthma was investigated among 7,505 youth (4-16 years old) in the Third National Health and Nutrition Examination Survey. Logistic regression models adjusted for potentially confounding variables, which generally had no effect on the coefficients for the antioxidants. Serum vitamin E had little or no association with asthma. In separate models, a SD increase in beta-carotene (odds ratio [OR], 0.9; 95% confidence interval [CI], 0.7, 1.0), vitamin C (OR, 0.8; 95% CI, 0.7, 0.9), and selenium (OR, 0.9; 95% CI, 0.7, 1.1) was associated with a 10-20% reduction in asthma prevalence. Serum cotinine was used to identify youth with no cigarette smoke exposure and passive exposure (7%): Active smokers were too few to be studied further. The selenium-asthma association was stronger in youth who were smoke exposed (p = 0.075). A SD increase in selenium was associated with a 50% reduction in asthma prevalence (OR, 0.5; 95% CI, 0.2, 1.4) in youth with passive smoke exposure compared with a 10% reduction in youth with no smoke exposure. The findings support an association of antioxidants with prevalent asthma, which for some antioxidants is stronger among children exposed to cigarette smoke.