TECHNICAL REPORT

Protecting Children From , , and Tobacco Smoke Harold J. Farber, MD, MSPH, FAAP, Judith Groner, MD, FAAP, Susan Walley, MD, FAAP, Kevin Nelson, MD, PhD, FAAP, SECTION ON

This technical report serves to provide the evidence base for the American abstract Academy of Pediatrics’ policy statements “Clinical Practice Policy to Protect Children From Tobacco, Nicotine, and Tobacco Smoke” and “Public Policy to Protect Children From Tobacco, Nicotine, and Tobacco Smoke.” Tobacco use and involuntary exposure are major preventable causes of morbidity and premature mortality in adults and children. Tobacco dependence almost always starts in childhood or adolescence. Electronic nicotine delivery systems are rapidly gaining popularity among youth, and their significant harms are being documented. In utero tobacco smoke exposure, in addition to increasing the risk of preterm birth, low birth weight, stillbirth, placental abruption, and sudden infant death, has been found to increase the risk of obesity and neurodevelopmental disorders. Actions by pediatricians can help to reduce children’s risk of developing tobacco dependence and reduce children’s involuntary tobacco smoke exposure. Public policy actions to protect children from tobacco are essential to reduce the toll that the tobacco epidemic takes on our children. This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial INTRODUCTION involvement in the development of the content of this publication. This technical report describes the evidence base for the American Technical reports from the American Academy of Pediatrics benefit ’ “ from expertise and resources of liaisons and internal (American Academy of Pediatrics policy statements Public Policy to Protect Children Academy of Pediatrics) and external reviewers. However, technical From Tobacco, Nicotine, and Tobacco Smoke” and “Clinical Practice Policy reports from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that ”1,2 to Protect Children From Tobacco, Nicotine, and Tobacco Smoke . they represent.

The goal of the present technical report is to document knowledge The guidance in this report does not indicate an exclusive course of regarding the harms of tobacco to children and adolescents and to treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. document the evidence for actions by clinicians and policy makers to All technical reports from the American Academy of Pediatrics reduce the toll that tobacco takes on children and adolescents. Because automatically expire 5 years after publication unless reaffirmed, comprehensive literature reviews and evaluations are conducted by the revised, or retired at or before that time. fi Of ce of the Surgeon General, the present report focused on additional www.pediatrics.org/cgi/doi/10.1542/peds.2015-3110 research findings subsequent to the Reports of the Surgeon General and DOI: 10.1542/peds.2015-3110 topics not well covered in those reports. When multiple studies produced similar findings, the best quality and/or most recent are presented with PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). reference to meta-analyses or authoritative statements (eg, Reports of the Copyright © 2015 by the American Academy of Pediatrics

Downloaded from www.aappublications.org/news by guest on September 29, 2021 PEDIATRICS Volume 136, number 5, November 2015 FROM THE AMERICAN ACADEMY OF PEDIATRICS Surgeon General, US Public Health Service recommendations or guidelines) when available. Relevant literature was identified by using PubMed searches and references cited in relevant review articles or authoritative statements. Each article was assessed for quality and relevance. Reports of the Surgeon General were identified from the Web site http://www.surgeongeneral.gov/ library/reports/index.html.

GRADING EVIDENCE ON THE HARMS OF TOBACCO Because it is unethical to conduct FIGURE 1 Evidence quality. RCT, randomized controlled trial. randomized controlled clinical trials among children with a substance that is harmful, the evidence related to the harms of tobacco has been graded as or unregulated by the US Food mechanical mods, vape pens, and follows: strong quality—consistent and Drug Administration (FDA), vaping devices. findings from double-blind, which is not approved for safe and randomized controlled clinical trials, effective tobacco dependence large representative-sample treatment. KEY FINDINGS • epidemiologic studies, good-quality Secondhand smoke: the smoke How Tobacco Harms Children meta-analyses incorporating large emitted from a tobacco product representative studies with consistent that is inhaled by a nonuser. 1. Tobacco product use is common among youth. Quality of evidence: results, and/or a Report of the • Thirdhand smoke: the tobacco strong Surgeon General of a “major smoke that is absorbed onto sur- conclusion” or “evidence is sufficient”; faces and exposes the nonuser by 2. More than one-half of children in good quality—well-performed, either direct contact and dermal the have evidence of generalizable case-control study, other absorption and/or off-gassing and tobacco smoke exposure. Quality well-performed epidemiologic study, inhalation. Thirdhand smoke may of evidence: strong other meta-analyses, and a Report of react with oxidants and other 3. Tobacco dependence creates the Surgeon General of “evidence is compounds in the environment to a substantial economic burden for suggestive”; or fair quality—other yield secondary pollutants.4 both civilian and military sectors. research study, small sample size, and • Involuntary tobacco smoke expo- Quality of evidence: strong fi ndings not replicated. sure: the tobacco smoke exposure 4. Tobacco kills people when used as of nonusers. Involuntary exposure intended. Quality of evidence: GRADING EVIDENCE FOR CLINICAL AND includes both secondhand and strong POLICY RECOMMENDATIONS thirdhand exposure. 5. Tobacco smoke exposure harms Evidence quality and strength of • Electronic nicotine delivery sys- children. Quality of evidence: recommendations were determined tems: handheld devices that pro- strong on the basis of guidelines of the duce an aerosol from a solution 6. Tobacco exposure harms the fetus. fl American Academy of Pediatrics’ typically containing nicotine, a- Quality of evidence: strong “ voring chemicals, and carrier sol- policy statement Classifying 7. Tobacco increases infant mortal- vents such as propylene glycol and Recommendations for Clinical ity. Quality of evidence: strong Practice Guidelines” and are vegetable glycerin (glycerol) for in- 8. Tobacco smoke exposure increases summarized in Fig 1 and Table 1.3 halation by the user. Alternate names for these products include asthma prevalence and severity. electronic , e-cigarettes, Quality of evidence: strong DEFINITIONS e-cigs, electronic cigars, e-cigars, 9. The effects of tobacco smoke ex- • Tobacco product: any nicotine de- electronic hookah, e-hookah, hookah posure on risk of asthma start in livery product, currently regulated sticks, personal vaporizers, utero. Quality of evidence: strong

Downloaded from www.aappublications.org/news by guest on September 29, 2021 e1440 FROM THE AMERICAN ACADEMY OF PEDIATRICS TABLE 1 Guideline Definitions for Evidence-Based Statements Recommended Actions for Pediatricians Statement Definition Implication 1. Inquire about tobacco use and to- Strong recommendation A strong recommendation in favor of Clinicians and policy makers should bacco smoke exposure as part of a particular action is made when follow a strong recommendation health supervision visits and visits fi the anticipated bene ts of the unless a clear and compelling for diseases that may be caused or recommended intervention clearly rationale for an alternative exceed the harms (as a strong approach is present exacerbated by tobacco smoke ex- recommendation against an action posure. Evidence quality: B; Rec- is made when the anticipated ommendation strength: strong harms clearly exceed the benefits) recommendation and the quality of the supporting evidence is excellent. In some 2. Include tobacco use prevention as clearly identified circumstances, part of anticipatory guidance. Evi- strong recommendations may be dence quality: B; Recommendation made when high-quality evidence strength: strong recommendation is impossible to obtain and the anticipated benefits strongly 3. Address parent/caregiver tobacco outweigh the harms dependence as part of pediatric Recommendation A recommendation in favor of Clinicians and policy makers would health care. Evidence quality: B; a particular action is made when be prudent to follow the anticipated benefits exceed the a recommendation but should Recommendation strength: strong harms, but the quality of evidence remain alert to new information recommendation is not as strong. Again, in some and sensitive to patient 3a. Recommend tobacco dependence clearly identified circumstances, preferences treatment of tobacco-dependent recommendations may be made parents and caregivers. Evi- when high-quality evidence is impossible to obtain but the dence quality: B; Recommen- anticipated benefits outweigh the dation strength: strong harms recommendation Option Options define courses that may be Clinicians and policy makers should taken when either the quality of consider the option in their 3b. Implement systems to identify evidence is suspect or carefully decision-making, and preference and offer counseling, treatment, performed studies have shown may play a substantial role treatment recommendations, little clear advantage to one and/or referral for tobacco- approach over another dependent parents. Evidence No recommendation No recommendation indicates that Clinicians and policy makers should there is a lack of pertinent be alert to new published evidence quality: C; Recommendation published evidence and that the that clarifies the balance of benefit strength: recommendation fi anticipated balance of bene ts and versus harm 4. Offer tobacco dependence treat- harms is presently unclear ment and/or referral to adoles- cents who want to stop . Evidence Quality: B; Recommen- 10. Tobacco smoke exposure increases 15. Tobacco smoke exposure of chil- dation strength: strong fi the severity of bronchiolitis. dren leads to ndings of pre- recommendation Quality of evidence: strong clinical atherosclerosis. Quality of 4a. Tobacco dependence pharma- 11. Tobacco smoke exposure increases evidence: strong cotherapy can be considered for risk for and severity of other re- 16. Tobacco smoke exposure moderate to severely tobacco- spiratory illnesses. Quality of evi- increases the risk of childhood dependent adolescents who want dence: strong cancers. Quality of evidence: to stop smoking. Evidence qual- 12. Tobacco smoke exposure increases good ity: D; Recommendation the risk of middle ear disease. 17. Smoke-free homes may reduce strength: option Quality of evidence: strong children’s tobacco smoke expo- 5. Offer tobacco-dependent individu- 13. In utero tobacco smoke exposure sure. Quality of evidence: good als quitline referral. Evidence increases the risk of being over- 18. Tobacco dependence almost al- quality: A; Recommendation weight in childhood. Quality of ways develops before reaching the strength: strong recommendation evidence: strong age of majority. Quality of evi- 6. Consider potential for neuropsychi- 14. Tobacco smoke exposure increases dence: strong atric symptoms with tobacco de- the risk of learning and neuro- 19. Tobacco dependence is a treatable pendence treatment. Evidence behavioral problems. Quality of chronic illness. Quality of evi- quality: C; Recommendation evidence: strong dence: strong strength: recommendation

Downloaded from www.aappublications.org/news by guest on September 29, 2021 PEDIATRICS Volume 136, number 5, November 2015 e1441 7. Do not recommend electronic nico- Recommendation strength: HOW TOBACCO HARMS CHILDREN tine delivery systems for tobacco strong recommendation dependence treatment. Evidence 1. Tobacco product use is common 8. Tobacco product prices should be among youth. quality: B; Recommendation increased to reduce youth tobacco Quality of evidence: strong strength: strong recommendation use initiation. Evidence quality: B; 8. If the sources of a child’s tobacco Recommendation strength: The 2012 Report of the Surgeon smoke exposure cannot be elimi- strong recommendation General concluded, “Almost one in nated, provide counseling about 9. The minimum age to purchase four high school seniors is a current ’ strategies to reduce the child s to- tobacco should be increased to 21 (in the past 30 days) bacco smoke exposure. Evidence years. Evidence quality: B; Rec- smoker, compared with one in three fi ” quality: C, Recommendation ommendation strength: strong young adults and one in ve adults. strength: recommendation recommendation Approximately 1 in 10 high school senior male students is a current 10. Flavoring agents, including men- Public Policy Recommendations smokeless tobacco user, and ∼1in5 thol, should be prohibited in all 1. The FDA should regulate all tobacco high school senior male students is tobacco products. Evidence qual- products to protect the public a current cigar smoker. Significant ity: B; Recommendation strength: health. Evidence quality: X; Rec- disparities in tobacco use remain strong recommendation ommendation strength: strong among young people nationwide. In recommendation Recommendations to Protect Children the United States, the prevalence of 2. Tobacco control should be ade- From Tobacco Smoke and Nicotine cigarette smoking is highest among quately funded. Evidence quality: A; Exposure American-Indian and Alaska Native Recommendation strength: strong 11. Comprehensive smoking bans people compared with other ethnic recommendation should be enacted. Evidence groups and highest among youth of quality: B; Recommendation lower socioeconomic status Recommendations for Public Policy to strength: strong recommendation compared with more affluent youth. Protect Children From Tobacco Use 12. Smoking in multi-unit housing The use of smokeless tobacco is Initiation fi should be prohibited. Evidence increasing among self-identi ed 3. Tobacco product advertising and quality: B; Recommendation white male high school students, and promotion in forms that are acces- strength: strong recommendation cigar smoking may be increasing sible to children and youth should among black female high school 13. Prohibitions on smoking and use be prohibited. Evidence quality: B; students.4 Recommendation strength: strong of tobacco products should include Table 2 describes the different recommendation prohibitions on use of electronic nicotine delivery systems. Evi- forms of tobacco currently available 4. Point-of-sale tobacco product ad- dence quality: B; Recommenda- in the United States. The 2012 US vertising and product placement tion strength: strong National Youth Tobacco Survey that can be viewed by children recommendation (NYTS) described 6.7% of middle should be prohibited. Evidence school students (5.6% of girls and quality: B; Recommendation Recommendations to Protect Children 7.8% of boys) as currently (ie, strength: strong recommendation From Acute within the last 30 days) using any 5. Depictions of tobacco products in 14. Children younger than 18 years tobacco products, with cigarettes movies and other media that can be should be legally prohibited from (3.1%), cigars (2.8%), smokeless viewed by youth should be re- working on tobacco farms and in tobacco (1.7%), pipes (1.8%), stricted. Evidence quality: B; Rec- tobacco production. Evidence hookahs (water pipes) (1.3%), ommendation strength: strong quality: C, Recommendation electronic cigarettes (e-cigarettes) recommendation strength: recommendation (1.1%), and Swedish snuff (snus) 6. The promotion and sale of elec- 15. Concentrated nicotine solution for (0.8%) as the most commonly used tronic nicotine delivery systems to electronic nicotine delivery sys- products. Among high school youth should be prohibited. Evi- tems should be sold in child- students, 23.3% (18% of girls and dence quality: B; Recommendation resistant containers with amounts 28% of boys) reported current (ie, strength: strong recommendation limited to that which would not be withinthelast30days)useofany 7. Tobacco control programs should lethal to a young child if ingested. tobacco product, with cigarettes change the image of tobacco by Evidence quality: B, Recommen- (14.0%), cigars (12.6%), smokeless telling the truth about tobacco. dation strength: strong tobacco (6.4%), pipes (4.5%), Evidence quality: B; recommendation hookahs (5.4%), e-cigarettes

Downloaded from www.aappublications.org/news by guest on September 29, 2021 e1442 FROM THE AMERICAN ACADEMY OF PEDIATRICS TABLE 2 Tobacco Products Currently Available in the United States (2.8%), and snus (2.5%) as the Product Description Comments most commonly used products.5 Cigarettes A small roll of paper that is filled Cigarettes are still the most Concurrent use of multiple tobacco with cut tobacco and smoked common form of tobacco used products is common. In the 2012 by youth NYTS, 9.9% of US high school Cigars and little cigars A tightly-rolled bundle of dried and In the United States, cigars are students reported use of 2 or more fermented tobacco, wrapped in exempt from many of the different tobacco products.6 a tobacco leaf. Cigars come in marketing regulations that a variety of flavors, including govern cigarettes, and cigars Analyses of data from the 2011 and “cherry,”“peach,” and “grape” are taxed at a far lower rate 2012 NYTS found that initiation than cigarettes. Flavors and rates for e-cigarette use doubled lower cost appeal to children. Little cigars are similar to from 1.4% to 2.7% among middle regular cigarettes, except school students and from 4.7% to wrapping is tobacco leaf rather 10.0% among high school students. than paper Current (ie, within the last 30 days) Pipes A tube with a small bowl at one Pipes use black (air-cured) end; used for smoking tobacco tobacco, which carries a higher e-cigarette use showed a similar risk of esophageal cancer pattern, with increases from 0.6% to Hookahs or narghile A single or multi-stemmed Longer duration of a smoking 1.1% of middle school students and instrument for smoking in which session and deeper inhalation 1.5% to 2.8% of high school students the smoke is cooled by passing leads to much higher smoke in the 2011–2012 period.7 Current through water intake than cigarette smoking Bidis (or ) A thin, South Asian cigarette filled Bidis must be puffed more rapidly data show that rates of e-cigarette with tobacco flake and wrapped than regular cigarettes to use are dramatically escalating in a tendu leaf tied with a string remain lit. Bidis contain more among youth, with the 2014 NYTS at 1 end tar, nicotine, and carbon reporting current (ie, within the last monoxide than the typical 30 days) e-cigarette use in 3.9% of cigarette Cigarettes made with a blend of Cloves contain eugenol, whose local middle school students and 13.4% tobacco, cloves, and other anesthetic effect allows deeper of high school students, increases flavors. The word “” is an inhalation of 650% and 890%, respectively, onomatopoetic term for the compared with 2011 data.8 The crackling sound of burning cloves Monitoring the Future survey Chewing tobacco Loose leaves, plugs, or twists of reported current (ie, within the last tobacco that are placed between 30 days) e-cigarette use among the cheek and gum 16.2% of 11th graders and 17.1% of Snuff Finely ground tobacco packaged in 12th graders in 2014.9 Hookah use cans or pouches, which can be sold dry (powdered form that is among youth is also rapidly sniffed) or moist (placed escalating, with 9.4% of high school between the lower lip or cheek students reporting hookah use and gum) according to the 2014 NYTS.8 Snus A moist powder tobacco product originating from a variant of dry Analysis of data from the Growing Up snuff. It is usually not fermented Today Study, a large, longitudinal Dissolvable tobacco Unlike ordinary chewing tobacco, it Discreet form, candy-like cohort of adolescents followed up dissolves in the mouth. Orbs or appearance, and added pellets look similar to small flavorings make them attractive from ages 12 to 24 years (N = 13 913), breath mints. Sticks similar to to young children found smoking initiation at younger toothpicks are for insertion ages and greater prevalence of between the upper lip and gum. smoking and amount smoked among Strips administer nicotine by homosexual and bisexual youth. Odds using thin-film drug delivery technology and look similar to of past-month smoking were 1.66 breath-freshening strips (95% confidence interval [CI]: Electronic nicotine delivery Battery-powered devices heat Flavors and promotion increase 1.22–2.28) and 1.57 (95% CI: systems, electronic a solution to create an aerosol. appeal to youth 1.28–1.94) for bisexual and gay male cigarettes, e-cigarettes, Devices usually contain nicotine, fl subjects, respectively, and 2.62 (95% e-cigs, hookah sticks, propylene glycol, and avoring – e-hookahs, e-cigars, agents. There is no regulation on CI: 2.31 2.97) and 2.12 (95% CI: e-pipes, mechanical contents or manufacturing 1.70–2.64) for bisexual and gay female mods, vape pens, others standards. Heating the mixture subjects relative to heterosexual creates other toxins. youth.10

Downloaded from www.aappublications.org/news by guest on September 29, 2021 PEDIATRICS Volume 136, number 5, November 2015 e1443 2. More than one-half of children in productivity because of premature Similar results were found in the United States have evidence of death, and $5.6 billion from lost a 25-year follow-up study of 49 539 tobacco smoke exposure. productivity because of exposure to Norwegian adults.22 The same Quality of evidence: strong secondhand smoke. Norwegian study found a synergistic effect of smoking and obesity on The National Health and Nutrition Tobacco use leads to a substantial mortality in middle age, with the Examination Survey (NHANES) burden for the armed services. A combination of heavy smoking and assesses a nationally representative 2009 Institute of Medicine report obesity leading to much greater sample of the noninstitutionalized US quotes the US Department of Defense premature mortality than either civilian population. Tobacco smoke Assistant Secretary of Defense for factor alone.23 A study in Finland exposure is indicated by a measurable Health Affairs, “Every year, tobacco comparing changes in smoking rates serum cotinine concentration. use leads to unnecessary with changes in lung cancer rates 20 Cotinine, a nicotine metabolite, is compromises in the readiness of our years later found a correlation close a biomarker of recent tobacco troops and costs the Department of to 1:1 (R2 = 0.95).24 exposure and can be measured in Defense millions of dollars in serum, urine, and saliva.11 In the preventable health care costs.” 2007–2008 NHANES, 53.6% (95% CI: Tobacco use can impair troops both 5. Tobacco smoke exposure harms 46.2–61.0) of children 3 to 11 years through the effects of tobacco smoke children. of age had evidence of tobacco smoke toxicants, including carbon monoxide, Quality of evidence: strong exposure. This amount is greater than and through nicotine withdrawal. The substantial harm of tobacco toxin the level of exposure in adults aged Analyses of data from TRICARE (the exposure for children has been 20 years or older, among whom health care program serving US extensively documented, with 36.7% (95% CI: 32.0–41.3) were uniformed service members, retirees, evidence summarized in the 2006 exposed. The 2007–2008 survey and their families) identified excess Report of the Surgeon General.25 results were similar to findings of the medical costs of approximately $228 Because nicotine and other tobacco 2001–2002 and 2005–2006 surveys per tobacco user per year, with toxins cross the placenta, children are and showed slightly less exposure retirees and dependents incurring harmed from exposure to tobacco than the 1999–2000 and 2003–2004 greater medical costs because of toxins starting in utero. This exposure surveys.12 tobacco use ($321) than active-duty ’ enrollees ($104) or their dependents can be both from the mother s Tobacco-dependent parents and ($106). Tobacco use in the military is tobacco product use as well as her caregivers are important sources of also associated with failure to exposure (via inhalation or children’s tobacco smoke exposure. A complete basic training and absorption) to the tobacco smoke of total of 519 children aged 3 to 12 premature discharge from the armed others. Children are harmed from years with a history of asthma and forces.15–17 secondhand tobacco smoke exposure tobacco smoke exposure were by breathing in the smoke emitted by enrolled in a clinical trial of an others who are using combustible intervention for reducing tobacco 4. Tobacco kills people when used as tobacco products. smoke exposure.13 The ratio of urine intended. Thirdhand tobacco smoke exposure is cotinine to creatinine was higher if Quality of evidence: strong increasingly being recognized as either the mother or caregiver were Tobacco use by youth and young another route of tobacco toxin tobacco smokers and highest if both adults has severe adverse health exposure.26 Thirdhand tobacco were smokers. consequences. This evidence has smoke is the smoke that remains on been summarized in multiple surfaces and in dust, which may be 3. Tobacco dependence creates Reports of the Surgeon General from re-emitted into the gas phase or may a substantial economic burden for 4,14,18–20 both civilian and military sectors. 1964 onward. The landmark react with oxidants and other 40-year prospective follow-up study compounds in the environment to Quality of evidence: strong of 34 439 male British physicians by yield secondary pollutants.27 Using rigorous methods, the 2014 Doll et al21 found that nearly one- Thirdhand smoke includes nicotine, Report of the Surgeon General half of all regular cigarette smokers tobacco-specific carcinogens, and determined that smoking-attributable died as a result of their addiction. other toxicants.28,29 Children can economic costs were $289 to $332.5 The age at which one-half of subjects absorb, ingest, and inhale these billion per year in the United States.14 had died was 8 years younger for substances. An analysis of house dust These costs include $132.5 to $175.9 smokers than for nonsmokers. The samples collected from private homes billion for direct medical care of risk of smoking-related disease was of tobacco smokers in northeastern adults, $151 billion for lost reduced by stopping smoking. Spain found tobacco-related

Downloaded from www.aappublications.org/news by guest on September 29, 2021 e1444 FROM THE AMERICAN ACADEMY OF PEDIATRICS carcinogens in the dust at levels pregnant women in Mumbai, India, 9 cigarettes per day (OR compared sufficient to increase the risk of found a substantial increased risk of with nonsmokers: 1.9 [95% CI: cancer.30 Young children may have stillbirth associated with maternal 1.7–2.0] and 1.7 [95% CI: 1.1–1.9] vs greater exposure because toddlers use of smokeless tobacco (OR: 2.6 1.5 [95% CI: 1.4–1.7] and 1.4 [95% CI: commonly explore by placing objects [95% CI: 1.4–4.8])35 and if the 1.2–1.5]).40 in the mouth. Children and mother did not smoke but was Both active maternal smoking and adolescents can also be harmed from exposed to the smoke of another secondhand maternal tobacco smoke 36 absorption of tobacco toxins when inside the home. A study in exposure have been shown to reduce they participate in tobacco Newfoundland, Canada, of 11 862 birth weight. A case-control study in 31,32 production. nonsmoking women with singleton Saudi Arabia compared birth gestations, of whom 11.1% reported outcomes of 1085 tobacco exposure to secondhand tobacco 6. Tobacco exposure harms the smoke–exposed women with those of fetus. smoke, found an increased risk of 2341 unexposed women with term, stillbirth with an adjusted OR of 3.35 singleton pregnancies. Mean birth Quality of evidence: strong. – 37 (95% CI: 1.16 9.72). A recent meta- weight was lower in the tobacco The 2014 Report of the Surgeon analysis found that maternal smoke–exposed women compared General found that the evidence is exposure to secondhand tobacco with the unexposed women (3.15 vs fi suf cient to conclude that tobacco smoke during pregnancy increased 3.21 kg; P = .002).41 In Rhode Island, smoking in early pregnancy causes the risk of stillbirth (OR: 1.23 [95% a longitudinal follow-up study of 119 14 – 38 orofacial clefts. CI: 1.09 1.38]). pregnant women enrolled in their In utero tobacco exposure from either Maternal smoking also increases the third trimester of pregnancy found maternal active tobacco product use risk of placenta-associated that birth weight was greater for or maternal secondhand tobacco complications of pregnancy. A case- nonsmoking women and women who smoke exposure increases the risk of control study in Finland compared stopped smoking during pregnancy stillbirth. The Missouri maternally 175 placental abruption case compared with those who continued linked cohort data set contains subjects with 370 delivery to smoke (mean birth weight: 3.46 information on both live births and time–matched control subjects.39 and 3.56 kg vs 3.16 kg, respectively; fetal deaths, with maternal smoking Thereweremoresmokersamong P =.004).42 When biomarkers of during pregnancy routinely case subjects (27.4% vs 14.3%; P , tobacco exposure in the infant’s documented on the birth certificate .001). Serum cotinine concentrations meconium were assayed, findings on the basis of the mother’s response were greater in case subjects were similar, with greater mean birth after delivery.33 The large data set compared with control subjects weight if biomarkers of tobacco included 57 965 stillbirth cases and (median: 229.5 vs 153.5 ng/mL; P = exposure were absent versus if those 51 436 413 live birth controls. There .002), and many more case subjects biomarkers were present (3.50 vs was a dose–response relationship, than control subjects had serum 3.20 kg; P , .001). A case-control with greater risk of stillbirth relating cotinine concentrations .15 ng/dL study in Lucknow, India, of mothers directly to the amount the mother (30.3% vs 17.6%; P , .001). These aged 20 to 30 years who did not use smoked. For deliveries at 20+ weeks’ findings provide biological tobacco compared those who had gestation, the risk of stillbirth was confirmation of the greater tobacco a low birth weight infant (,2.5 kg) increased compared with exposure in case subjects compared versus those who did not have a low nonsmokers, with an odds ratio (OR) with control subjects. An analysis of birth weight infant ($2.5 kg).43 After of 1.43 (95% CI: 1.31–1.57) if the data from the Missouri Electronic adjusting for other factors associated mother smoked .1 pack per day and Vital Records system of 1 312 505 with low birth weight, a history of an OR of 1.31 (95% CI: 1.22–1.41) if singletonbirthsat20to44weeks’ tobacco smoke exposure (ie, active the mother smoked one-half to 1 pack gestation found that if the mother smoker in the home smoked in their per day. A study using data from the was a smoker, the risk of placental presence) increased the odds for low Swedish Medical Birth Register (with abruption and placenta previa were birth weight (adjusted OR: 3.16 [95% 2322 stillbirths and 851 371 live substantially greater (0.71% vs 1.27% CI: 1.9–5.3]). Similar findings were births) found that, compared with [P , .01] and 0.35% vs 0.48% [P , noted in a retrospective cohort study mothers who did not use tobacco, the .01], respectively). A dose–response in Newfoundland, Canada, of risk of stillbirth increased for mothers relationship was observed; the ORs for nonsmoking women with singleton who were tobacco smokers (adjusted placental abruption and placenta gestations.37 A total of 1202 women OR: 1.59 [95% CI: 1.40–1.80]) and previa were greater for those who with a history of tobacco smoke snus users (adjusted OR: 1.43 [95% smoked $20 cigarettes per day exposure were compared with CI: 1.02–1.99]).34 A study of 1110 compared with those who smoked 0 to 10 650 women with no tobacco

Downloaded from www.aappublications.org/news by guest on September 29, 2021 PEDIATRICS Volume 136, number 5, November 2015 e1445 smoke exposure. Mean birth weight smoking restrictions.47 Similar relationship between parental was lower for the smoke-exposed reductions in preterm birth were smoking and ever having asthma women (3.43 vs 3.51 kg; P , .0001), observed coinciding with the among children of school age. The and the odds of low birth weight implementation of smoke-free evidence is sufficient to infer a causal (,2.5 kg) were also greater for the legislation in Scotland.48 relationship between secondhand smoke-exposed women (OR: 1.65 smoke exposure from parental [95% CI: 1.29–2.09]). 7. Tobacco increases infant smoking and the onset of wheeze mortality. ”25 Maternal smoking and tobacco smoke illnesses in early childhood. The exposure increase the risk of preterm Quality of evidence: strong Bogalusa Heart Study showed that asthma prevalence was consistently birth. A birth cohort study of 10 095 Using 2005–2009 data, the 2014 greater in children whose mothers nonsmoking women aged .18 years Report of the Surgeon General were smokers, with nearly 3000 who had a singleton live birth in determined that children surveyed on 3 occasions Lanzhou, China, found that maternal during pregnancy results in nearly between 1983 and 1994; ORs ranged tobacco smoke exposure was 1000 infant deaths per year or ∼8% from 1.35 (95% CI: 1.01–1.81) to 1.51 associated with an increased risk of of all infant deaths and 17% of all (95% CI: 1.17–1.96) depending on very preterm (,32 weeks’ gestation) cases of sudden infant death survey year.53 Among children aged 1 birth, with a dose–response syndrome (SIDS).14 relationship demonstrated.44 For to 16 years hospitalized for asthma, Tobacco smoke exposure increases an those exposed to smoke for ,1 hour having detectable salivary cotinine infant’s risk of SIDS. This conclusion per day, the OR for a very preterm levels was associated with increased was a major finding of the 2006 birth was 1.89 (95% CI: 1.26–2.84), odds of readmission within 12 Report of the Surgeon General.25 Both and for those exposed to $1 hour per months (adjusted OR: 2.35 [95% CI: prenatal and postnatal exposure – 54 day, the OR for a very preterm birth 1.22 4.55]). Among 466 children contributes to the risk. Association of was 2.61 (95% CI: 1.56–4.34) enrolled in the CHIRAH ( in utero tobacco smoke exposure with compared with mothers who were Initiative to Raise Asthma Health abnormalities of sleep arousal not exposed to smoke. An analysis of Equity) study, increases in salivary responses has been data from the Swedish Medical Birth cotinine concentrations were demonstrated.49–51 A recent Dutch Register found that the risk of associated with an increased risk of case-control study compared 142 55 preterm birth was increased for both asthma exacerbations. SIDS case subjects versus 2841 maternal snus use (adjusted OR: 1.27 Implementation of smoke-free control subjects recruited from well- [95% CI: 1.14–1.41]) and maternal legislation led to decreases in infant clinics. The study found that, smoking at 1 to 9 cigarettes per day childhood asthma hospitalizations in compared with nonsmoking parents, 56,57 and $10 cigarettes per day (adjusted England and Scotland. parental smoking led to an increased OR: 1.24 [95% CI: 1.17–1.32] and risk of SIDS, with the risk greater if 9. The effects of tobacco smoke 1.56 [95% CI: 1.44–1.69], both parents were smokers (OR: 5.8 exposure on risk of asthma start in respectively).45 Analysis of data from [95% CI: 2.2–15.5]) versus if 1 parent utero. the Generation R study, a longitudinal was a smoker (OR: 2.5 [95% CI: follow-up study from early pregnancy Quality of evidence: strong 1.2–5.0]), thus demonstrating onward of 9778 mothers and their Prenatal tobacco smoke exposure a dose–response effect.52 children living in Rotterdam, the adversely affects lung development. Netherlands, found that continued In a cohort of 4574 mothers and their 8. Tobacco smoke exposure maternal smoking after pregnancy children prospectively followed up increases asthma prevalence and fi was associated with low birth weight severity. from pregnancy through the rst 4 (adjusted OR: 1.75 [95% CI: years of the child’s life, exposure to 1.20–2.56]) and preterm birth Quality of evidence: strong maternal smoking when in utero as (adjusted OR: 1.36 [95% CI: Tobacco smoke exposure increases well as secondhand smoke after birth 1.04–1.78]) in the fully adjusted the risk of asthma, wheezing, and were associated with increased risk models.46 An ecologic study in asthma exacerbations in children. The for wheezing at 2 to 4 years of age.58 Belgium found that after introduction 2006 Report of the Surgeon General History of in utero tobacco smoke of staged smoke-free legislation (first concluded, “The evidence is sufficient exposure was associated with greater workplaces, then restaurants, then to infer a causal relationship between rates of poor asthma control in 2481 bars that serve food), rates of preterm parental smoking and cough, phlegm, Latino and African-American children birth decreased, with further wheeze, and breathlessness among with asthma when assessed at 8 to 17 decreases in preterm birth rates with children of school age. The evidence years of age.59 A prospective follow- each successive escalation of the is sufficient to infer a causal up study of 1129 children from birth

Downloaded from www.aappublications.org/news by guest on September 29, 2021 e1446 FROM THE AMERICAN ACADEMY OF PEDIATRICS to 14 years of age found that supplemental oxygen and needing a child younger than 5 years found maternal smoking during pregnancy mechanical ventilation during the that having 1 or more smokers in the was associated with current asthma, hospitalization (ORs: 2.45 [95% CI: household was associated with an current wheeze, and exercise-induced 1.60–3.74] and 5.49 [95% CI: increased risk of hospitalization for wheeze (ORs: 1.84 [95% CI: 2.78–10.83], respectively).63 A case- pneumonia in the previous 12 1.16–2.92], 1.77 [95% CI: 1.14–2.75], control study of infants born at 32 to months (adjusted OR: 1.55 [95% CI: and 2.29 [95% CI: 1.37–3.85], 35 weeks’ gestation found that 1.25–1.92]).67 The Cincinnati respectively).60 Analyses of data from smoking in the presence of the child Childhood Allergy and Air Pollution the CAMP (Childhood Asthma and maternal smoking during Study prospectively followed up Management Program) study found pregnancy were more common in the children from the newborn period.68 that a history of in utero tobacco cases with RSV hospitalization (ORs: At 7 years of age, lung function and smoke exposure markedly attenuated 1.59 [95% CI: 1.12–2.26] and 1.62 hair cotinine data were available on the benefit of inhaled corticosteroid [95% CI: 1.17–2.24]).64 According to 486 members of the cohort. Significant response among children aged 5 to 12 a prospective follow-up study of 217 reductions in forced expiratory years with persistent asthma and healthy newborn infants from a single volume in 1 second (0.03 L, P , .05) demonstrated airway pediatric center in Denmark, a history and mean forced expiratory flow hyperreactivity.61 A meta-analysis of smoking in the household was between 25% and 75% of the forced of 79 prospective epidemiologic associated with a higher risk of vital capacity (0.06 L/s, P , .01) were studies published between 1997 hospitalization because of RSV in the seen for every log-unit change in and February 2011 assessed the first year of life (OR: 5.06 [95% CI: cotinine concentration. A survey of association between tobacco smoke 1.36–18.76]).65 A systematic 1718 children in third and fourth exposure and the incidence of literature review of studies assessing grades in Guangzhou, China, found wheeze or asthma in childhood; it the effect of tobacco smoke exposure increased sneezing and coughing at found that prenatal maternal on RSV bronchiolitis in children night among those with tobacco smoking and household secondhand aged younger than 5 years identified smoke exposure inside the home.69 tobacco smoke exposure were 30 relevant articles published A study of 117 children younger than associated with an increased risk between1990and2009.66 The 15 years hospitalized for influenza of asthma.62 review found a consistent impact found that the risk of ICU admission of tobacco smoke exposure on and length of stay were greater 10. Tobacco smoke exposure risk of hospitalizations for RSV among children with a history of increases the severity of disease. secondhand tobacco smoke exposure bronchiolitis. (adjusted OR of 4.7 [95% CI: Quality of evidence: strong 11. Tobacco smoke exposure 1.4–18.5] and adjusted incidence increases risk for and severity of – In utero and secondhand tobacco rate ratio of 1.7 [95% CI: 1.2 2.3], other respiratory illnesses. 70 smoke exposure of children leads to respectively). A meta-analysis of more severe episodes of bronchiolitis. Quality of evidence: strong 60 studies published before # The 2006 Report of the Surgeon Tobacco smoke exposure increases November 2010 of infants aged 2 fi General concluded, “Smoking by the risk of pneumonia and cough. The years con rmed that smoking by any parents causes respiratory symptoms 2006 Report of the Surgeon General household member, paternal and slows lung growth in their concluded, “The evidence is sufficient smoking, maternal prenatal smoking, children.” It also concluded, “The to infer a causal relationship between and maternal postnatal smoking all ’ evidence is sufficient to infer a causal parental smoking and cough, phlegm, increased the risk of an infant s relationship between secondhand wheeze, and breathlessness among lower respiratory tract infection – smoke exposure from parental children of school age”; “The evidence (ORs: 1.54 [95% CI: 1.40 1.69], 1.22 – smoking and lower respiratory tract is sufficient to infer a causal [95% CI: 1.10 1.35], 1.58 [95% CI: – illnesses in infants and children.”25 relationship between maternal 1.45 1.73], and 1.24 [95% CI: – 71 The increased risk of lower smoking during pregnancy and 1.11 1.38]). respiratory illnesses is greatest from persistent adverse effects on lung 12. Tobacco smoke exposure smoking by the mother. A study in function across childhood”; and “The fi increases the risk of middle ear Liverpool, United Kingdom, of 378 evidence is suf cient to infer a causal disease. infants hospitalized for bronchiolitis, relationship between exposure to of whom 299 (79%) had respiratory secondhand smoke after birth and Quality of evidence: strong syncytial virus (RSV) infection, found a lower level of lung function during The 2006 Report of the Surgeon that having a household tobacco childhood.”25 A population survey in General concluded, “The evidence is smoker increased the odds of needing Vietnam of 24 781 households with sufficient to infer a causal

Downloaded from www.aappublications.org/news by guest on September 29, 2021 PEDIATRICS Volume 136, number 5, November 2015 e1447 relationship between parental healthy term infants in the United them and their children smoking and middle ear disease in Kingdom.76 Maternal smoking during prospectively.80 Maternal smoking children, including acute and pregnancy was associated with an and smoke exposure were assessed recurrent otitis media and chronic increased risk of the child being during pregnancy, and child behavior middle ear effusion.”25 Using data overweight at 3 years of age problems were assessed at 18 months from the 91 642 interviews (adjusted OR: 1.33 [95% CI: for 4329 mother–child dyads. completed for the 2007–2008 US 1.15–1.55]). A meta-analysis of Maternal smoking during pregnancy National Survey of Children’s Health, studies published from 1990 to May and paternal smoking were both an association of secondhand smoke 2011 identified 7 relevant studies associated with increased behavior exposure with recurrent ear and confirmed the effect of maternal problems for the child; however, infections for children older than 6 smoking during pregnancy on these findings were not robust to years was demonstrated (adjusted the risk of the children being statistical adjustment for ORs of 1.48 [95% CI: 0.98–2.21] for overweight (adjusted OR: 1.47 psychosocial variables. A study in age 6–11 years and 1.67 [95% CI: [95% CI: 1.26–1.73]).77 Finland of administrative data on 1.02–2.72] for age 12–17 years).72 A 175 869 children born 1987 through meta-analysis published in 2012 14. Tobacco smoke exposure 1989 found that maternal smoking found that maternal postnatal increases the risk of learning and increased the risk of having smoking (20 studies) and household neurobehavioral problems. a psychiatric diagnosis through 18 smoking (49 studies) increased the Quality of evidence: strong years of age in analyses controlling risk for otitis media, with ORs of 1.62 The 2014 Report of the Surgeon for maternal psychiatric diagnosis – ’ 81 (95% CI: 1.33 1.97) and 1.37 (95% General concluded, “The evidence is and child s gender. – 73 CI: 1.25 1.50), respectively. sufficient to infer that nicotine A birth cohort study in Brisbane, exposure during fetal development, Australia, assessed maternal smoking 13. In utero tobacco smoke exposure a critical window for brain starting at the first prenatal visit.82 At increases the risk of being ’ overweight in childhood. development, has lasting adverse 14 years of age, the child s academic consequences for brain development,” performance was assessed according Quality of evidence: strong and “The evidence is suggestive but to mother’s report. Rate of academic Both active smoking and secondhand not sufficient to infer a causal performance below average was tobacco smoke exposure of the relationship between maternal greater if the mother smoked during mother during pregnancy increase prenatal smoking and disruptive pregnancy (adjusted OR: 1.35 [95% the child’s later risk of being behavioral disorders, and attention CI: 1.07–1.70]), with findings robust overweight. A prospective follow-up deficit hyperactivity disorder in to adjustment for multiple potential study included 7924 infants of particular, among children.”14 confounding variables, including nonsmoking mothers who were born Analysis of data from the 2007 US maternal age, income, education, in Hong Kong in April or May 1997, National Survey of Children’s Health alcohol consumption, family with maternal secondhand tobacco found that having a history of communication, and behavior smoke exposure determined at the someone who smokes inside the problems. An analysis of first postnatal visit.74 Of those infants, home increased the child’s risk of computerized population data for 6790 (86%) had their BMI measured having attention-deficit/hyperactivity children born in Sweden between at 7 to 11 years of age. Children of disorder, learning disabilities, and/or 1983 and 1987 merged results from daily paternal smokers had higher conduct disorders reported (adjusted birth registries, school and education mean BMI z scores at 7 to 11 years of ORs: 1.44 [95% CI: 1.21–1.72], 1.54 registries, and census data.83 The age, with a mean difference in BMI of [95% CI: 1.27–1.85], and 1.78 [95% study found that the risk of poor 0.10 (95% CI: 0.02–0.19) at 7 years CI 1.44–2.21], respectively).78 A school performance at 15 years of age and 0.16 (95% CI: 0.07–0.26) at 11 survey of 5494 preschool-aged (mean score below passing) was years. A retrospective cohort study of children in Bavaria, Germany, greater if the mother smoked during 1366 fourth grade students in confirmed that a history of pregnancy, with a dose–response Kumagaya City, Japan, found that secondhand tobacco smoke exposure effect demonstrated. The OR for poor those with a history of maternal was associated with an increase in school performance was 1.58 (95% smoking during pregnancy had conduct problems and hyperactivity/ CI: 1.53–1.62) if the mother smoked 1 a higher mean 6 SD BMI (17.2 6 2.7 inattention that was independent of to 9 cigarettes per day and 1.89 (95% vs 16.9 6 2.5; P = .016) when the effect of maternal smoking before CI: 1.83–1.96) if the mother smoked assessed at 9 to 10 years of age.75 The and during pregnancy.79 The $10 cigarettes per day during Millennium Cohort Study Generation R Study enrolled mothers pregnancy. These findings were prospectively followed up 18 296 early in pregnancy and observed robust to statistical adjustment for

Downloaded from www.aappublications.org/news by guest on September 29, 2021 e1448 FROM THE AMERICAN ACADEMY OF PEDIATRICS maternal and birth characteristics. generally has a greater effect on Shiraz, Iran, found that paternal The NHANES III (1988–1994) a child’s level of tobacco smoke smoking before and during pregnancy included both measurement of serum exposure.13 and maternal secondhand smoke cotinine concentrations and Soluble intercellular adhesion exposure during pregnancy were assessments of academic molecule 1 (s-ICAM1) is a measure of associated with an increased cancer performance for children 6 to 16 endothelial stress, and hair cotinine is risk in children, with ORs of 1.8 (95% years of age in the United States.84 CI: 1.4–6.0), 3.0 (95% CI: 1.4–5.0), a biomarker of tobacco smoke Children’s tobacco exposure, as and 3.6 (95% CI: 1.3–5.0), exposure. In a sample of children assessed by using serum cotinine respectively.92 The Australian Study aged 9 to 18 years in Columbus, Ohio, concentrations, was significantly of Childhood Brain Tumors, a national hair cotinine concentrations were associated with lower scores for population-based case-control study positively correlated with s-ICAM1 reading, math, and visuospatial skills, conducted between 2005 and levels.89 A substantial amount of the with even very low cotinine 2010, found that maternal smoking variance in s-ICAM1 was accounted concentrations seeming to have an before and during pregnancy was for by hair cotinine level of the child effect. Findings were robust to associated with increased risk of (partial R2 = 0.26, P = .0001 for the statistical adjustment for potentially brain tumors diagnosed before association of log hair cotinine with confounding variables. 2 years of age, with ORs of 5.06 s-ICAM1 level in multivariate models (95% CI: 1.35–19.00) and 4.61 adjusting for BMI, age, mean blood 15. Tobacco smoke exposure of (95% CI: 1.08–19.63).93 children leads to findings of pressure, and very low-density preclinical atherosclerosis. lipoprotein level). 17. Smoke-free homes may Quality of evidence: strong reduce children’s tobacco smoke 16. Tobacco smoke exposure exposure. A cohort of 545 children in Finland increases the risk of childhood Quality of evidence: good prospectively followed up from cancers. infancy through adolescence had Quality of evidence: good Smoke-free homes and cars may serum cotinine concentrations reduce children’s tobacco smoke measured annually between 8 and 13 The 2006 Report of the Surgeon exposure but are unlikely to “ years of age.85 Carotid intima-media General concluded, The evidence is completely protect a child as long as fi thickness was greater and peak suggestive but not suf cient to infer household members are smokers. A flow–mediated dilation of the brachial a causal relationship between randomized controlled trial of an artery was lower in children in the prenatal and postnatal exposure to intensive intervention to implement highest tertile of tobacco smoke secondhand smoke and childhood smoke-free homes in Ankara, Turkey, ”25 exposure. Similar results were found cancer. Additional evidence of an found substantial reductions in urine in a study of 16-year-old male association between childhood cotinine levels over 12 months of adolescents (N = 610) in Lhasa City, cancers and tobacco smoke exposure follow-up in the intervention group Tibet,86 and in a case-control study of has accumulated since this 2006 but not in the control group.94 A healthy young adults.87 Using pooled report. Tobacco-specific carcinogens randomized controlled study among data from the Cardiovascular Risk in have been detected in the blood of Latino families in Houston, Texas, in Young Finns study (Finland) and the children who have a tobacco smoker which an adult was a smoker Childhood Determinants of Adult in the home.90 A case-control study of compared provision of 2 culturally Health study (Australia), exposure to children with acute lymphoblastic appropriate fotonovelas (illustrated parental smoking was assessed in leukemia (ALL) in Australia found storybooks) and 1 comic book, which 3416 children and carotid intima- that a history of paternal smoking of were designed to promote a tobacco- media thickness was assessed in $15 cigarettes per day during the free indoor environment, versus use adulthood, 21 to 28 years later. If pregnancy year was associated with of a standard both parents smoked at baseline, the an increased risk of childhood ALL, guide published by the American child’s carotid intima-media thickness with an OR of 1.46 (95% CI: Cancer Society. At the 12-month in adulthood was greater (mean: 1.05–2.01).91 The authors then follow-up, there were more reported 0.652 vs 0.637 mm; P = .003 in fully pooled their results with 9 other bans on in-home smoking for the adjusted analyses).88 This study did relevant studies and documented intervention (fotonovela) condition not find that smoking by 1 parent had a modest increased risk of paternal (73% vs 56%). Although the results an effect; however, the study did not prenatal smoking on childhood ALL, did not differ according to differentiate maternal from paternal with an OR of 1.15 (95% CI: intervention group, those homes with smoking. This omission may be 1.06–1.24). A case-control study of an in-home smoking ban had reduced important because maternal smoking childhood (,14 years) cancers in nicotine concentrations on the home

Downloaded from www.aappublications.org/news by guest on September 29, 2021 PEDIATRICS Volume 136, number 5, November 2015 e1449 surfaces sampled (0.04 6 0.04 mg/m3 19. Tobacco dependence is remissions, the longer acting vs 0.47 6 0.66 mg/m3; P , .01).95 A a treatable chronic illness. medications can be thought of as study in Columbus, Ohio, of children Quality of evidence: strong “controllers,” with the faster acting younger than 3 years found that medications used as “relievers.” The 2008 US Public Health when the mother was a smoker, hair Service–sponsored clinical practice In studies of tobacco-dependent cotinine concentrations were not guideline advised that “Clinicians adults, initiation of nicotine significantly different if the mother strongly recommend the use of replacement therapy before stopping reported smoking inside or effective tobacco dependence smoking improves the effectiveness outside.96 counseling and medication of treatment. A multisite, randomized treatments to their patients who use clinical trial with parallel groups 18. Tobacco dependence almost tobacco, and that health systems, (placebo and active treatment– always develops before reaching the insurers, and purchasers assist controlled) included 400 tobacco- age of majority. clinicians in making such effective dependent adult subjects in North Quality of evidence: strong treatments available.”100 Even brief Carolina.104 It provided an advice can increase quit rates.101 intervention of a 21-mg nicotine Tobacco is a substance of abuse. The patch versus placebo daily for 2 2012 Report of the Surgeon General A 2013 Cochrane review concluded weeks before cessation, with active concluded, “Given their that nicotine replacement therapy, (no placebos) provided developmental stage, adolescents and bupropion, varenicline, and cytisine for all subjects after the stop smoking young adults are uniquely susceptible (a nicotine receptor partial agonist, date. Precessation treatment with the to social and environmental not currently available in the United nicotine patch substantially improved influences to use tobacco,” and States) improved the chances of fi “Among adults who become daily stopping smoking.102 Combination quit rates, with the greatest bene t smokers, nearly all first use of nicotine replacement therapy for those with lower levels of nicotine cigarettes occurs by 18 years of age outperformed single formulations. dependence (Fagerström Test for (88%), with 99% of first use by 26 Forms of nicotine replacement Nicotine Dependence [FTND] score , years of age.”4 therapy that are approved by the FDA 6). For smokers with lower FTND for tobacco dependence treatment are scores, 10-week continuous Nicotine dependence develops early nicotine patches, , and abstinence rates were 33.8% in and drives the progression from nicotine lozenges (available over the the precessation nicotine patch intermittent to daily smoking. A study counter in the United States) as well condition versus 9.3% in the placebo of 1246 English-speaking students as nicotine nasal spray and nicotine patch condition. In contrast, from central Massachusetts enrolled inhalers (available only by for smokers with higher FTND students in sixth grade and prescription in the United States). scores, abstinence rates did not monitored them prospectively for 4 differ significantly between years.97,98 Of the 370 subjects who The 2009 American College of Chest patch conditions (14.0% in the had inhaled from a cigarette, the Physicians’ Tobacco Dependence precessation nicotine patch condition median age at first cigarette use was Treatment ToolKit advises, vs 10.8% in the placebo patch 12 years. At least 1 symptom of early “Approaching tobacco dependence as condition). A meta-analysis identified nicotine dependence was reported by a chronic disease acknowledges the 4 relevant studies completed before 33% of participants who had ever altered central nervous system (CNS) February 2007 and found that puffed on a cigarette. Experiencing neurobiology in tobacco-dependent precessation therapy with a nicotine any symptom of nicotine dependence patients. The goal of therapy in patch doubled abstinence rates at 6 increased the risk of progressing to tobacco dependence is to normalize weeks and 6 months (ORs: 1.96 [95% monthly smoking (adjusted hazard brain function—so that the patient CI: 1.31–2.93] and 2.20 [95% CI: ratio: 3.7 [95% CI: 2.4–5.5]) or daily has minimal to no symptoms of 1.39–3.48], respectively).105 smoking (adjusted hazard ratio: 6.8 nicotine withdrawal, thus allowing [95% CI: 4.4–10.5]). Analyses of the patient to feel (near) normal For further details on practical, data from the 2004 NYTS found that while not using tobacco. The intensity evidence-based, expert consensus among the 2580 adolescent smokers of treatment should be based on the recommendations for tobacco aged 12 to 18 years who severity level of nicotine dependence. dependence treatment, the reader participated in the survey, there was For highly nicotine-dependent is referred to the American College a strong correlation between patients, combination therapy is often of Chest Physicians’ Tobacco nicotine withdrawal symptoms and needed.”103 Adhering to the model of Dependence Treatment ToolKit both the amount and frequency of asthma and other chronic diseases (http://tobaccodependence.chestnet. smoking.99 regarding exacerbations and org).

Downloaded from www.aappublications.org/news by guest on September 29, 2021 e1450 FROM THE AMERICAN ACADEMY OF PEDIATRICS RECOMMENDED ACTIONS FOR 2. Include tobacco use prevention as who were tobacco smokers were PEDIATRICIANS part of anticipatory guidance. interested in stopping smoking; 56.5% were at the contemplation or 1. Inquire about tobacco use and Evidence quality: B better stage of change.13 tobacco smoke exposure as part of health supervision visits and visits Recommendation strength: strong Tobacco dependence treatment or for diseases that may be caused or recommendation recommendation for treatment by exacerbated by tobacco smoke The US Preventive Services Task pediatricians is acceptable to most exposure. Force (USPSTF) recommends that parents. A nationally representative Evidence quality: B primary care clinicians provide (US) telephonic survey included 730 interventions, including education or parents who had accompanied a child to a health care visit in the past year, Recommendation strength: strong brief counseling, to prevent initiation recommendation of tobacco use in school-aged children of whom 21% were tobacco 111 and adolescents.109 The USPSTF smokers. The survey found that It is important to identify tobacco report concluded, “The USPSTF found most (59.7%) of the smokers thought use so that appropriate adequate evidence that behavioral it would be acceptable to have the interventions can be offered to ’ counseling interventions, such as child s physicians prescribe or prevent tobacco use initiation, face-to-face or phone interaction with recommend a tobacco dependence recommend stopping smoking, and/ a health care provider, print treatment medication for them. or recommend treatment of tobacco materials, and computer applications, dependence. It is important that can reduce the risk for smoking 3a. Recommend tobacco dependence tobacco smoke exposure be initiation in school-aged children and treatment of tobacco-dependent identified so that interventions can parents and caregivers. adolescents.” A meta-analysis of be offered to reduce this exposure. behaviorally based interventions to Evidence quality: B The Memphis Health Project, prevent tobacco use initiation found a longitudinal study of smoking in 10 relevant trials with a pooled risk Recommendation strength: strong 5154 adolescents, found that ratio of 0.81 (95% CI: 0.70–0.93).110 recommendation participants who were both screened and advised had more According to the US Public Health 3. Address parent/caregiver tobacco – knowledge about the health risks of dependence as part of pediatric Service sponsored evidence-based smoking and more negative health care. guideline Treating Tobacco Use and Dependence: 2008 Update, perceptions of the social value of Evidence quality: B smoking than participants with no “Counseling and medication are intervention or screening.106 Recall effective when used by themselves for Recommendation strength: strong treating tobacco dependence. The of physician communication was recommendation associated by teenagers with combination of counseling and improved perceptions of the dangers Because tobacco smoke exposure is medication, however, is more of smoking. The adolescents who harmful to the child, and parental effective than either alone. Thus, were smokers reported more quit tobacco smoking is an important clinicians should encourage all adults ’ attempts and fewer intentions to source of a child s tobacco smoke making an attempt to stop tobacco to continue to smoke when they exposure, addressing parental and use both counseling and ”100 reported recall of physician advice. caregiver tobacco dependence is medication. Analyses of data from the 18 866 important in protecting the health of Behaviorally based interventions for respondents of the 2011 NYTS found the child. According to the US Public parental tobacco dependence have – low rates of recalled health care Health Service sponsored evidence- limited benefit; interventions that provider screening for tobacco use based guideline Treating Tobacco Use include use of medications show “ (32.2% [95% CI: 30.2–34.1]).107 and Dependence: 2008 Update, It is greater efficacy. A clinical trial of Among current youth smokers, essential that clinicians and health cotinine feedback and behavioral receipt of health professional care delivery systems consistently counseling for parents of tobacco counseling was associated with identify and document tobacco use smoke–exposed children with asthma having made an attempt to stop status and treat every tobacco user found no significant intervention ”100 smoking (OR: 1.39 [95% CI: seen in a health care setting. effect; however, on subgroup 1.15–1.68]). Similar results were An assessment of parents of tobacco analyses, children with high-risk foundonanalysesofdatafromthe smoke–exposed children with asthma asthma who received the intervention 24 573 participants in the 2000 who enrolled in a clinical trial found had a greater reduction in the ratio of NYTS.108 that most of the primary caregivers urine cotinine to creatinine than did

Downloaded from www.aappublications.org/news by guest on September 29, 2021 PEDIATRICS Volume 136, number 5, November 2015 e1451 the control group.112 A meta-analysis TABLE 3 Counseling Approaches of studies designed to protect CEASE program: Ask, Assist, Refer114,188 children from tobacco smoke Ask. Does your child live with anyone who uses tobacco? exposure through parental cessation Assist. Assist families to stop using tobacco and eliminating tobacco smoke exposure. This assistance or modification of parental smoking includes both counseling and recommendations or prescriptions for medication fi Refer. Refer families who use tobacco for outside help, such as the state or national telephonic quitline identi ed 18 relevant studies (1-800-QUIT-NOW in the United States) published through March 2011.113 American College of Chest Physicians Tobacco Dependence Treatment ToolKit: Assess, Recommend, Studies had substantial variation in Monitor, Revise103 the methods and interventions tested. Assess and diagnose The relative risk of parental smoking Recommend a treatment plan. The treatment plan should be based on the level of nicotine dependence, with more dependent patients needing cessation from the pooled study more aggressive therapy results was 1.34 (95% CI: 1.05–1.71). Monitor the treatment plan’s outcome The impact was greatest in the Revise the treatment plan to improve effectiveness and minimize adverse effects. Base effectiveness on subgroup of 2 studies that included achieving control of nicotine withdrawal – 189 the use of nicotine replacement ASKNOW: A Stage of Change theory based counseling strategy Assess the health behavior therapy in the intervention (risk Determine the stage of change ratio: 3.13 [95% CI: 1.19–8.21]). Keep in mind key facts Jointly negotiate an action plan 3b. Implement systems to identify Observe outcome in follow-up and offer counseling, treatment, Work toward the next stage 103,190 treatment recommendations, and/or Stage of Change theory of health behavior change — referral for tobacco-dependent Precontemplation Patient has no intention of changing behavior parents. Stage-matched interventions include: 1. Assess roadblocks to the proposed change Evidence quality: C 2. Discuss the relevance, risks, and rewards of the proposed change 3. Determine what action the patient and/or family is willing to take Contemplation—Patient intends to make the behavior change within the next 6 mo but makes no Recommendation strength: commitment to action recommendation Stage-matched interventions include: 1. Assess roadblocks, including level of nicotine dependence Practical systems have been 2. Assess opportunities to overcome roadblocks developed and validated to address 3. Recommend appropriate pharmacotherapy parental tobacco dependence as part 4. Build confidence that the patient can make a change that has beneficial results of the child’s health care. A summary Preparation—The intention is to implement the behavior change soon, within 1 month of counseling approaches is described Stage-matched interventions include: 1. Assess the specific changes needed in Table 3. A randomized controlled 2. Recommend and/or prescribe appropriate pharmacotherapy clinical trial involving 22 practices in 3. Facilitate the development of specific plans for smoking cessation the Pediatric Research in Office Action—Patient has made the behavior change recently (within the past 6 mo); relapse risk is at its Settings network tested the use of the highest Clinical Effort Against Secondhand Stage-matched interventions: 1. Monitor for difficulties and lapses Smoke Exposure (CEASE) program.114 2. Discuss strategies to recover from them The intervention included: (1) routine a. Consider if treatment plan needs modification screening for parental tobacco use; 3. Discuss how to handle difficult situation (2) motivational messaging based on 4. Provide positive reinforcement the parents’ own concerns; and (3) Maintenance—Six months to life postchange; the risk of relapse is still present, although not as high Stage-matched interventions: recommendation and possible 1. Ask about lapses and temptations to lapse provision of nicotine patch and gum 2. If nicotine withdrawal symptoms are in good control, consider if pharmacotherapy can be stepped by the clinician and enrollment in the down free state (telephone) quitline. On exit CEASE, Clinical Effort Against Secondhand Smoke Exposure. interview, parental smokers in the intervention practices reported a higher rate of discussing methods to Before prescribing tobacco appropriate assessment of disease stop smoking (24% vs 2%; P , .001), dependence treatment for parents, (tobacco dependence), consider prescription of nicotine replacement pediatricians should verify that their possible contraindications to the medication (12% vs 0%; P , .001), medical liability insurance provides medications, counsel about risks and and enrollment in the state coverage for care offered to adults. If benefits, offer recommendations for (telephonic) quitline (10% vs 0%; the pediatrician elects to prescribe for follow-up, and provide appropriate P , .001). parents, he or she should conduct an treatment. Follow-up is important to

Downloaded from www.aappublications.org/news by guest on September 29, 2021 e1452 FROM THE AMERICAN ACADEMY OF PEDIATRICS monitor for adherence to treatment intensive interventions, even brief receiving the nicotine patch, 17.4% of recommendations, adverse effects of counseling by physicians can be of those receiving the nicotine gum, and medications prescribed or used, assistance, with effects enhanced by 5.0% of the placebo group were not correct technique for use of the repeated advice.101 smoking (P = .02 for patch versus recommended treatments, adequacy placebo). By 3 months after Although still beneficial compared of treatment in controlling nicotine pharmacotherapy was discontinued, with nonintervention, behaviorally withdrawal symptoms, and stage of nonsmoking rates were 20.6% for the based programs have much lower change in relation to stopping tobacco patch, 8.7% for the gum, and 5% for rates of smoking cessation among use and in relation to accepting placebo (P = .06 for patch versus teenagers who are severely tobacco tobacco dependence treatment. placebo). Adherence to daily use of dependent. For example, Project EX Pediatricians should follow state the patch was acceptable at 78.4%; (an 8-session, school-based clinic regulations and institutional policies adherencetouseofthenicotine tobacco use cessation program for for charting on care provided for gum was poor at 38.5%. Analyses of adolescents that includes enjoyable, parents and caregivers to benefit the trial participants who had stopped motivating activities) found that 30- health of the child. Electronic health smoking and then restarted found day abstinence from smoking on record systems should facilitate that those who restarted smoking completion of the program was 42% adherence to documentation after a period of abstinence had for those with minimal to mild requirements without placing greater craving scores, suggesting tobacco dependence but only 7% for excessive burdens on the parent or that inadequately controlled those with severe tobacco pediatrician. withdrawal contributed to the dependence.116 Similar results were lapse.121 A randomized, double- found in evaluation of the Not On 4. Offer tobacco dependence blind, placebo-controlled, parallel- ’ treatment and/or referral to Tobacco program; at 3 months group clinical trial included 6 weeks adolescents who want to stop follow-up, 24% of those with minimal of bupropion plus counseling for smoking. to mild nicotine dependence reported tobacco-dependent adolescents.122 Evidence quality: B not smoking, but only 9.4% of those Theauthorsfoundimprovedrates with severe nicotine dependence of smoking cessation with 150 mg 117 Recommendation strength: strong reported not smoking. Clinical of bupropion twice daily when recommendation trials of motivational interviewing the medication was being taken (29% versus brief advice (without abstinent at 6 weeks with bupropion 4a. Tobacco dependence medication use) for tobacco- vs 16% with placebo [P = .02]); the pharmacotherapy can be considered dependent adolescents yielded very benefit was quickly lost after the for moderate to severely tobacco- low stop-smoking rates that did not medication was stopped, however. dependent adolescents who want to differ between treatment stop smoking. groups.118,119 Because there has been limited research on tobacco dependence Evidence quality: D There is emerging evidence pharmacotherapy in adolescents, fi documenting a bene tof the FDA-approved labeling for Recommendation strength: option pharmacotherapy for tobacco- these medications states, “Safety Tobacco dependence treatment of dependent adolescents; adherence is and effectiveness in the pediatric adolescents has varying degrees of challenging, however, and relapse population have not been success in stopping smoking, with after brief courses of treatment is established.” Because tobacco results contingent on the severity of common. Investigators compared the dependence is a severe chronic the dependence. Behaviorally based use of a nicotine patch versus illness that debilitates, harms programs for tobacco-dependent nicotine gum versus placebo in offspring, and shortens life, it is adolescents are effective and are most a randomized, double-blind, placebo- reasonable to consider that beneficial for those with minimal to controlled clinical trial with 120 pharmacotherapy documented as mild degrees of dependence. The adolescents who wanted to stop effective in adults is an option for the most effective of the behaviorally smoking and had moderate or greater treatment of adolescents with based programs are developmentally tobacco dependence.120 Medication moderate to severe tobacco relevant and focus on contingency was initiated on the planned stop- dependence. Given the high rates of management skills, stage of change- smoking day and continued for 12 nonadherence during therapy and based motivational interviewing, weeks. Group cognitive behavioral relapse after discontinuation of social support, or a combination of therapy was provided to all therapy among adolescents in the these methods.115 Although more participants. At 1 week after the stop- trials of these medications, close benefit is observed with more smoking date, 26.5% of those follow-up is recommended.

Downloaded from www.aappublications.org/news by guest on September 29, 2021 PEDIATRICS Volume 136, number 5, November 2015 e1453 5. Offer tobacco-dependent samples and youth with bipolar In addition to nicotine, carcinogens, individuals quitline referral. disorder demonstrate an association toxins, metals, and silicates have been Evidence quality: A between tobacco use and suicide found in the emissions from these risk.128,129 In postmarketing devices.133–135 The adverse effects of Recommendation strength: strong surveillance, suicidal ideation and long-term inhalation of the flavoring recommendation suicide have been reported among agents used is not known, and some patients taking varenicline and Studies among adults found that commonly used agents are known bupropion, with a black box 136 free (to the user) telephonic tobacco respiratory irritants. warning issued by the FDA for both dependence treatment is beneficial; Pediatricians should direct patients medications.130 A study of 119 546 however, research among teenagers who want pharmacotherapy for adults in England who used is not yet available, and the services tobacco dependence to therapies a smoking cessation product found no provided vary substantially. Callers that have been documented to be differences in rates of treated to the California Smokers’ Helpline effective and are approved as depression, nonfatal self-harm, and during periods of high call volume such by the FDA. In New Zealand, fatal self-harm within 3 months of the who were ready to stop smoking a clinical trial of e-cigarettes first smoking cessation prescription; were randomized to be immediately for smoking cessation among the study compared those who assigned to a counselor (treatment) moderately to severely tobacco- received varenicline or bupropion or asked to call back (control).123 dependent adults found low with those who received nicotine All callers were sent written self- cessation rates and no statistically replacement.131 Neuropsychiatric help materials. Twelve-month significant difference between symptoms associated with tobacco abstinence rates were 9.1% in the the use of nicotine-containing dependence treatment may reflect treatment group versus 6.9% in 137 inadequate control of nicotine e-cigarettes and placebo. the control group (P , .001), with withdrawal.103 Among adolescents, the use of theentiredifferenceinthecontrol e-cigarettes is associated with group attributable to those Comorbidities of substance abuse decreased rates of stopping members who did not call back to and psychiatric disorders may smoking. A nationally representative receive assistance. A recent accompany tobacco dependence14 Cochrane review of telephonic and can make tobacco dependence survey of middle and high school counseling for smoking cessation more difficult to treat. These students in Korea found that among found 77 trials that met inclusion comorbidities, when identified, current adolescent smokers, criteria.124 Among smokers who should be addressed through although there were more attempts contacted helplines, quit rates were appropriate referral. to stop smoking among e-cigarette higher for groups randomized to users (OR: 1.67 [95% CI: The risk of treatment-emergent – receivemultiplesessionsof 1.48 1.90]), current e-cigarette neuropsychiatric symptoms should users were much less likely to have proactive counseling (9 studies, be balanced against the substantial .24 000 participants; relative risk stopped using cigarettes (OR: 0.10 harms of continued tobacco use. As [95% CI: 0.09–0.12]) compared for cessation at longest follow-up: with any other prescribing, the – with smokers who never used 1.37 [95% CI: 1.26 1.50]). discussion of risks versus benefits e-cigarettes.138 An analysis of 2011 should be documented in the health 6. Consider potential for and 2012 NYTS data found that record. neuropsychiatric symptoms with amongsmokers(havingsmokedat tobacco dependence treatment. least 100 cigarettes in their lifetime) 7. Do not recommend electronic Evidence quality: C nicotine delivery systems for who had ever used e-cigarettes, tobacco dependence treatment. both ever having used e-cigarettes Recommendation strength: and current e-cigarette use were Evidence quality: B recommendation associated with lower rates of Pediatricians should be aware of the abstinence from cigarette smoking increased risk of suicidal ideation Recommendation strength: strong (ORs of 0.32 [95% CI: 0.18–0.56] and suicide, both among continuing recommendation and 0.34 [95% CI: 0.13–0.87], smokers and among those being Electronic nicotine delivery systems respectively, for 1 year or greater treated for tobacco dependence. In have not been shown to be effective abstinence; ORs of 0.61 [95% CI: studies among adults, suicide is for smoking cessation.132 There is 0.42–0.89] and 0.35 [95% CI: associated with cigarette use in currently no regulation on content or 0.18–0.69] for more than 30 days a dose-dependent manner.125–127 manufacturing standards for but less than 6 months’ abstinence Studies of adolescent population electronic nicotine delivery systems. from cigarettes).139

Downloaded from www.aappublications.org/news by guest on September 29, 2021 e1454 FROM THE AMERICAN ACADEMY OF PEDIATRICS 8. If the sources of a child’s tobacco was reported in 41% of the sample. 2. Tobacco control should be smoke exposure cannot be The report of an in-home smoking adequately funded. eliminated, provide counseling about ban was associated with decreased Evidence quality: A ’ strategies to reduce the child s hair cotinine levels, although the tobacco smoke exposure. ’ child s hair nicotine level did not Recommendation strength: strong Evidence quality: C differ regardless of whether the recommendation mother reported smoking outside only. Tobacco dependence treatment Recommendation strength: should be available to tobacco- recommendation A single-blind, randomized dependent individuals of all ages. A randomized, single-blind study of controlled clinical trial of cotinine Given the important benefits to 352 children aged 8 to 16 years in feedback plus behavioral counseling society of reducing tobacco Ankara, Turkey, tested a smoke-free to reduce tobacco smoke exposure dependence, cost should not be – home intervention aimed at among tobacco smoke exposed a barrier to program participation increasing household smoking bans children with asthma in Northern and access to tobacco dependence and reducing secondhand smoke California found no overall treatment medications. The Best exposure. Those randomized to the intervention effect; however, the Practices for Comprehensive Tobacco smoke-free home intervention had subgroup of children with high-risk Control Programs—2014 guidelines greater rates of in-home smoking asthma had lower urine cotinine from the Centers for Disease Control 112 restrictions and substantially lower levels on follow-up. and Prevention (CDC) should be urine cotinine levels at 2, 6, and 12 implemented with funding at or near months of follow-up.94 A randomized, recommended levels.143 This single-blind study in 91 Mexican- PUBLIC POLICY RECOMMENDATIONS funding will ensure that tobacco American households used low control programs are available to literacy fotonovelas and a comic book 1. The FDA should regulate all those who need them. tobacco products to protect the to promote a tobacco-free indoor air The CDC’s Community Preventive 95 public health. environment. The study found that Services Task Force evidence a greater proportion of households in Evidence quality: X review found strong support for the intervention group implemented the effectiveness of comprehensive bans on smoking inside of the home. Recommendation strength: strong tobacco control programs in Although the study found no recommendation reducing tobacco use and differences in ambient nicotine level The FDA is charged with the mission secondhand smoke exposure, according to intervention group, independent of increases in tobacco those households that implemented of protecting consumers and enhancing public health by product prices or adoption of a ban on smoking indoors had lower smoke-free policies.144 These ambient nicotine levels than maximizing compliance of FDA- regulated products and minimizing programs reduce the prevalence of households that did not implement tobacco use among adults and young such a ban. risks associated with those products. The FDA Center for Tobacco Products people, reduce tobacco product A randomized single-blind study is responsible for carrying out the consumption, increase quitting, compared an in-home motivational Family Smoking Prevention and and contribute to reductions in interviewing intervention versus Tobacco Control Act, passed in 2009 tobacco-related diseases and deaths. provision of written information by in an effort to protect the public and Increases in program funding are mail in households with children aged create a healthier future for all associated with increases in , 3 years and a parent/caregiver who Americans.141 This act puts in place program effectiveness, with the 140 is a smoker. Ambient nicotine restrictions on marketing tobacco greatest impact seen if programs are levels measured in the kitchen and products to children and gives the funded at CDC-recommended levels. the room with a television were lower FDA the authority to take action in Tobacco control research should be in the motivational interviewing the future to protect public health. considered a high priority and intervention group than in the Some of the agency’s responsibilities funded accordingly from both written information control group. under the law include setting government and private sources. A convenience sample of 291 children performance standards, reviewing funding should ages 2 weeks to 3 years was recruited premarketing applications for new not be used for this purpose. The from a clinic that serves and modified-risk tobacco products, tobacco industry has a long history predominantly low-income families in and requiring new warning labels for of using industry-funded programs Columbus, Ohio.96 Maternal smoking tobacco products.142 to divert attention away from

Downloaded from www.aappublications.org/news by guest on September 29, 2021 PEDIATRICS Volume 136, number 5, November 2015 e1455 effective tobacco control programs that youth who reported higher 13 to 17 years were substantially and research, as well as misusing levels of exposure to advertisements less likely to try purchasing tobacco health care providers and academia in retail establishments had higher products when tobacco products to thwart attempts at tobacco rates of trying snus and e-cigarettes were not displayed (OR: 0.30 [95% control.14 (adjusted ORs: 3.33 [95% CI: CI: 0.1320.67]).149 2.66–4.18] and 1.71 [95% CI: Recommendations for Public Policy 1.21–2.41], respectively) comparing to Protect Children From Tobacco 5. Depictions of tobacco products in Use Initiation mostofthetimeoralwaysviewing movies and other media that can be retail tobacco advertisements viewed by youth should be restricted. 3. Tobacco product advertising and versus never or rarely.145 Students promotion in forms that are accessible in Tracy, California, were surveyed to children and youth should be Evidence quality: B prohibited. in grades 6 through 8 with follow-up surveys at approximately 12 months Evidence quality: B and 30 months later. Convenience Recommendation strength: strong stores, small markets, and liquor recommendation Recommendation strength: strong stores typically contain the most Depictions of smoking in the movies recommendation cigarette advertising. These cues have been repeatedly shown to were noticeable to students who had increase rates of smoking initiation Tobacco promotion is an important never smoked, with 82.1% of the cause of initiation of tobacco use among adolescents both in the sample reporting seeing cigarette among youth. Major conclusions of United States and globally. The 2012 advertisements in stores. The study the 2012 Report of the Surgeon Report of the Surgeon General found that a moderate (0.5–1.9 per “ General included, “Advertising and concluded, The evidence is week) and high (2.0–18 per week) fi promotional activities by tobacco suf cient to conclude that there is number of visits to these stores companies have been shown to cause a causal relationship between were associated with increased the onset and continuation of depictions of smoking in the movies rates of smoking initiation at 12 smoking among adolescents and and the initiation of smoking among months (ORs: 1.64 [95% CI: ”4 young adults.” The report also young people. In a prospective 1.06–2.55] and 2.58 [95% CI: concluded, “In 2008, tobacco study of a nationally representative 1.68–3.97])andat30months’ companies spent $9.94 billion on the sample of US adolescents aged 10 to follow-up (ORs: 1.19 [95% CI: marketing of cigarettes and $547 14 years recruited in 2003 and 1.00–1.41])and1.42[95%CI: million on the marketing of followedupfor24months,the 1.19–1.69]).146 The results from the smokeless tobacco. Spending on adjusted hazard ratios for smoking 2005–2006 California Student cigarette marketing is 48% higher initiation were 1.90 (95% CI: Tobacco Survey were matched to – than in 1998,” and “The evidence is 1.47 2.45), 1.91 (95% CI: retailer licensing data about the – suggestive but not sufficient to 1.49 2.44),and2.02(95%CI: location of tobacco outlets and with – conclude that tobacco companies 1.52 2.67) for views of tobacco use observations regarding the quantity have changed the packaging and bynegative,mixed,andpositive of cigarette advertising in a random 150 design of their products in ways that movie characters, respectively. A sample of those stores. The study have increased these products’ school-based prospective follow-up found that the prevalence of current 6 appeal to adolescents and young study of 9987 children (mean SD smoking was 3.2 percentage points 6 adults.”4 age: 13.15 1.10 years) in 6 higher at schools in neighborhoods European countries documented an 4. Point-of-sale tobacco product with the highest tobacco outlet adjusted incidence rate ratio for advertising and product placement that density (.5outlets)thanin smoking initiation of 1.13 (95% CI: can be viewed by children should be neighborhoods with no tobacco 1.08–1.17) for each additional 1000 prohibited. outlets.147 Analyses of data from occurrences of movie smoking the 1999–2003 Monitoring the exposure.151 A school-based cross- Evidence quality: B Future surveys matched to data sectional survey of 4943 on retail cigarette marketing adolescents 12 to 16 years of age in Recommendation strength: strong found that higher levels of NewDelhi,India,foundthatthe recommendation advertising, lower cigarette prices, adjusted odds of ever having used Point-of-sale advertising increases and greater availability of cigarette tobacco among adolescents with tobacco initiation and tobacco promotions were associated with high exposure to smoking in movies product use among youth. Analysis smoking uptake.148 Avirtualstore was 2.3 (95% CI: 1.3–3.9) compared of data from the 2011 NYTS found experiment found that youth aged with those with low exposure.152

Downloaded from www.aappublications.org/news by guest on September 29, 2021 e1456 FROM THE AMERICAN ACADEMY OF PEDIATRICS 6. The promotion and sale of electronic the initiation or prevalence of since 1980. In January 2008, Panama nicotine delivery systems to youth smoking among young people.”4 adopted Law No. 13, which intensified should be prohibited. The Best Practices for Comprehensive tobacco control measures by Tobacco Control Programs—2014 of prohibiting pro-tobacco statements on Evidence quality: B the CDC concluded the following: cigarette packages; requiring complete prohibition of any form of pro-tobacco “Mass-reach health communication advertising, promotion, or sponsorship Recommendation strength: strong interventions can be powerful tools recommendation in all venues, including sports venues; for preventing the initiation of prohibiting tobacco consumption in all Nicotine is a highly addictive tobacco use, promoting and enclosed work environments; and substance. The 2010 Report of the facilitating cessation, and shaping requiring the integration of content on Surgeon General produced a major social norms related to tobacco the health consequences of tobacco conclusion: “Nicotine is the key use.”143 The Community Preventive consumption into the curricula of chemical compound that causes and Services Task Force (2013) general education and basic secondary sustains the powerful addicting recommended mass-reach health education.155 From 2002 to 2008, the effects of commercial tobacco communication interventions based prevalence of current cigarette products.”20 Electronic nicotine on strong evidence of effectiveness in smoking among students 13 to 15 delivery systems have the potential to decreasing the prevalence of tobacco years of age in Panama decreased serve as introductory products and to use, increasing cessation and use of from 13.2% to 4.3%. escalate levels of nicotine dependence available services such as quitlines, among youth. An analysis of 2011 and and decreasing the initiation of Pictorial health warnings improve 2012 NYTS data found that among tobacco use among young people.153 adolescents’ awareness of the harms cigarette experimenters (ever smoked of smoking and decrease their Adolescents and young adults are a puff), a history of both ever and perceptions of the social appeal of very sensitive to perceived social current e-cigarette use was smoking. A survey of 4482 adolescents associated with being a current norms and media presentations of in Melbourne, Australia, found that cigarette smoker (ORs: 5.96 [95% CI: smoking behavior. Florida adolescents had more accurate fi 5.67–6.27] and 7.88 [95% CI: appropriated $23 million in scal perceptions of the health risks of fi 6.01–10.32], respectively).139 year 1997 and $70 million in scal smoking if they had seen the graphic year 1998 to fund the Florida warnings.156 Focus groups of 7. Tobacco control programs should Tobacco Pilot Program to prevent and adolescents in Auckland, New Zealand, change the image of tobacco by telling ’ reduce tobacco use among Florida s found that graphic warning labels the truth about tobacco. 154 ’ youth. The program s major clearly prompted a more severe component was a youth-oriented, judgement of smokers’ social appeal.157 Evidence quality: B countermarketing media campaign developed to reduce the allure of 8. Tobacco product prices should be Recommendation strength: strong smoking; the other program increased to reduce youth tobacco use recommendation components comprise community initiation. Tobacco control programs that partnerships in all 67 Florida denormalize tobacco use by changing counties, an education and training Evidence quality: B the image that youth have about initiative, and enhanced enforcement tobacco and nicotine products can be of youth tobacco access laws. From Recommendation strength: strong effective. Tobacco industry–sponsored 1998 to 1999, the prevalence of recommendation programs have been ineffective. current cigarette use declined from The US Task Force on Community The 2012 Report of the Surgeon 18.5% to 15.0% (P , .01) among Preventive Services (2001) strongly General concluded, “The evidence middle school students and from recommended increasing the unit is sufficient to conclude that school- 27.4% to 25.2% (P = .02) among high price for tobacco products to reduce based programs with evidence of school students. Current cigar use smoking initiation and reduce effectiveness, containing specific declined among middle school consumption of tobacco products.158 components, can produce at least students from 14.1% in 1998 to Data from the Global Youth Tobacco short-term effects and reduce the 11.9% in 1999 (P , .01). Smokeless Survey were matched to data on prevalence of tobacco use among tobacco use declined among middle cigarette prices and estimated overall school-aged youth,” and “The tobacco school students from 6.9% in 1998 to price elasticity (the relationship companies’ activities and programs 4.9% in 1999. This decline has been between demand for a product and for the prevention of youth smoking larger than any annual decline its price) at –1.5; for low- and middle- have not demonstrated an impact on observed nationally among youth income countries, however, price

Downloaded from www.aappublications.org/news by guest on September 29, 2021 PEDIATRICS Volume 136, number 5, November 2015 e1457 elasticity was greater at –2.2, age. Only 14% had started daily Longitudinal Tobacco Use Reduction suggesting that a 10% price increase smoking at $20 years of age. Younger Study, middle school and high school would decrease youth smoking by age at starting smoking was students were surveyed in 3 waves 22%.159 Increasing the tobacco tax associated with a lower probability of from 2000 to 2003.167 Of those who has the benefit of both raising the stopping smoking. For example, 18% initiated smoking, 39% used menthol price and providing a source of funds of smokers who started at #13 years cigarettes. This percentage was that can be used for tobacco control of age had stopped within 10 years, higher for African-American programs. compared with 42% of those who respondents (52%) compared with all started at $20 years of age.163 other ethnic groups. Initiating 9. The minimum age to purchase Enforcement activities are important smoking with menthol cigarettes was tobacco should be increased to 21 associated with greater risk of years. for age-of-purchase laws to be effective. A 2005 Cochrane review on progression to established smoking – interventions for preventing tobacco (OR: 1.80 [95% CI: 1.02 3.16]). An Evidence quality: B sales to minors found that active analysis of data from the 2000 and enforcement, including media 2002 NYTS found that menthol Recommendation strength: strong coverage of that enforcement, was cigarettes were most popular among 168 recommendation much more efficacious than younger and newer smokers. In 2005, Needham, Massachusetts, educational programs alone.164 A Teenagers in middle school who had raised the minimum age for the 2011 comprehensive literature been smoking for less than 1 year purchase of tobacco to 21 years; by review found that enforcement were more likely to smoke menthol 2010, the youth smoking rate had programs which disrupted the sale of cigarettes than middle school dropped by nearly one-half (12.9% to tobacco to minors reduced smoking students who had been smoking for 6.7%), a change not observed in among youth, whereas merely more than 1 year (62.4% vs 53.3%; surrounding communities.160 The enacting a law without sufficient P = .002). Smokers of menthol fi minimum age for the legal purchase enforcement had minimal, if any, cigarettes were signi cantly less “ of tobacco increased from 16 to 18 impact on youth tobacco use.165 likely to be seriously thinking of ” years in England, Scotland, and Wales quitting within the next 30 days on October 1, 2007. Data from the 10. Flavoring agents, including menthol, (adjusted OR: 0.79 [P = .012]). A 2003–2008 Smoking, Drinking and should be prohibited in all tobacco survey of 1800 adolescents in New products. Drug Use Among Young People in York City found that the likelihood England, an annual survey of youths of current smoking was greater for fl aged 11 to 15 years, reported Evidence quality: B teenagers who had tried avored a substantial reduction in regular tobacco products (OR: 2.70 [95% CI: – smoking among 11- to 15-year-olds Recommendation strength: strong 1.47 4.98]) or menthol cigarettes – 169 after the minimum age was increased recommendation (OR: 15.16 [95% CI: 8.34 27.57]). – (adjusted OR: 0.67 [95% CI: Flavoring agents increase the appeal A2010 2011 survey of Canadian high 0.55–0.81]).161 In Massachusetts of tobacco products to youth. Tobacco school students found that 52% of cities in which compliance with use initiation and progression to these young tobacco consumers fl underage purchase was enforced and tobacco dependence are more reported use of avored tobacco 170 verified, focus groups of adolescent common with the use of the flavored products. fl smokers found that for high products. The only avoring agent Recommendations to Protect – school aged smokers, teenage store currently allowed in cigarettes is Children From Tobacco Smoke and clerks and friends who are aged $18 menthol, but small cigars and Nicotine Exposure years are major sources of attaining electronic nicotine delivery systems 162 11. Comprehensive smoking bans tobacco products. An analysis of are not subject to the same should be enacted. Canada’s 1994–1995 National regulations and are commonly Population Health Survey found that flavored. Analysis of data from the Evidence quality: B most smokers began daily smoking in National Youth Smoking Cessation their teenage years, with 16% of 21- Survey and the Assessing Hardcore to 39-year-olds who had ever smoked Smoking Survey found that flavored Recommendation strength: strong daily reporting that they had started cigarette use was more common recommendation to do so at #13 years of age; 55% among 17-year-olds than among The 2006 Report of the Surgeon reported starting smoking at 14 to 17 older smokers (23% for 17-year-old General concluded, “Workplace years of age; and 15% reported smokers vs 9% for 22- to 26-year-old smoking restrictions are effective in starting smoking at 18 or 19 years of smokers).166 In the American Legacy reducing secondhand smoke

Downloaded from www.aappublications.org/news by guest on September 29, 2021 e1458 FROM THE AMERICAN ACADEMY OF PEDIATRICS exposure. Total bans on indoor study of nonsmokers sitting in the 2001–2006 NHANES results for smoking in hospitals, restaurants, a parked car with an open window children who lived in nonsmoking bars, and offices substantially reduce while a smoker smoked 3 cigarettes residences found greater mean secondhand smoke exposure. over 1 hour found substantially cotinine concentrations among Exposures of non-smokers to elevated levels of cotinine as well as children who lived in apartments than secondhand smoke cannot be other tobacco-related toxicants and those who lived in attached or controlled by air cleaning or carcinogens after the in-vehicle detached houses (0.075, 0.053, and mechanical air exchange. Evidence tobacco smoke exposure.174,175 The 0.031 ng/mL, respectively; P , .01).181 from multiple peer-reviewed studies levels of polycyclic aromatic shows that smoke-free policies and hydrocarbons in the vehicles after 13. Prohibitions on smoking and use of tobacco products should include regulations do not have an adverse smoking 3 cigarettes with a window prohibitions on use of electronic economic impact on the hospitality open was higher than measurements nicotine delivery systems. industry.”25 Scotland implemented made in highly polluted urban traffic a comprehensive ban on smoking in or in bars and restaurants where Evidence quality: B public places in March 2006.57 Before smoking was allowed.176 After the legislation was implemented, passage of legislation in Maine Recommendation strength: strong admissions for asthma in children prohibiting smoking in vehicles when recommendation younger than 15 years were a child is present, smoke-free car increasing at a mean rate of 5.2% per policies among households with The aerosol emitted from electronic year (95% CI: 3.9–6.6); after children and a current smoker nicotine delivery systems contains implementation, there was a mean increased substantially, from 19.2% to toxic and carcinogenic substances in reduction in the rate of admissions of 30.7% (Behavioral Risk Factor addition to nicotine. A laboratory 18.2% per year relative to the rate on Surveillance System data).177 study of indoor air quality after March 26, 2006 (95% CI: 14.7–21.8). indoor e-cigarette use by volunteers 12. Smoking in multi-unit housing Enactment and enforcement of a law found substantial amounts of 1,2- should be prohibited. regarding smoke-free public places in propanediol, glycerin, and nicotine as Lexington-Fayette County, Kentucky, well as high concentrations of Evidence quality: B led to a reduction in emergency particulate matter less than 2.5 department visits for asthma for all micrometers in diameter (PM2.5) Recommendation strength: strong m 3 ages, with an 18% decline for recommendation (mean: 197 g/m ). Polyaromatic children and a 24% decline in hydrocarbons (carcinogens) Smoking in multi-unit housing exposes 3 182 adults.171 In Toronto, Ontario, increased by 20% to 147 ng/m . children to tobacco smoke. A survey of An analysis of the content of the Canada, asthma hospitalizations Minnesota residents of common decreased after implementation of aerosol from e-cigarettes found toxic, interest communities (eg, irritating, and carcinogenic comprehensive smoke-free policies; condominiums, cooperatives) found no such changes were observed in substances, including formaldehyde, that 28% of households reported acetaldehyde, and acrolein; volatile nearby cities that did not implement secondhand smoke incursion into their similar policies, and they were also organic compounds such as toluene unit in the preceding 6 months; 59% of and m,p-xylene; tobacco-specific not observed for common those surveyed said this infiltration gastrointestinal (ie, non–tobacco- nitrosamines; and the heavy metals bothered them a lot.178 Asurveyof 134 172 cadmium, nickel, and lead. related) conditions. 5936 residents of multi-unit housing Smoking in motor vehicles leads to who participated in the New York Recommendations to Protect substantial tobacco smoke exposure State Adult Tobacco Survey between Children From Acute Nicotine for nonsmokers. Laws prohibiting May 2007 and May 2009 found that Poisoning smoking in vehicles with children among respondents with a smoke-free 14. Children younger than 18 years present improved reports of not home policy, 46.2% reported should be legally prohibited from allowing smoking inside of the car. secondhand smoke entering their working on tobacco farms and in Studies of tobacco smoking in home in the past year, with 9.2% tobacco production. automobiles found that although open reporting daily incursions.179 Passive windows in a moving vehicle nicotine monitors in low-income multi- Evidence quality: C substantially improve air exchange unit residences in the greater rates, a significant amount of tobacco area detected nicotine in 89% (17 of Recommendation strength: smoke (measured as particulate mass 19) of nonsmoking homes, indicating recommendation concentrations) remains in the vehicle secondhand tobacco smoke Green tobacco sickness is a well- even with the windows open.173 A infiltration.180 An analysis of data from described entity. Dermal absorption

Downloaded from www.aappublications.org/news by guest on September 29, 2021 PEDIATRICS Volume 136, number 5, November 2015 e1459 of nicotine from moist tobacco plants CONCLUSIONS REFERENCES can lead to symptoms of severe Tobacco dependence starts in childhood. 1. American Academy of Pediatrics nicotine poisoning, including The tobacco epidemic takes a substantial Section on Tobacco Control. Policy weakness, headache, nausea, toll on children’s health, and the harm statement: public policy to protect vomiting, dizziness, abdominal starts in utero. There is strong evidence children from tobacco, nicotine, and fi cramps, breathing dif culty, pallor, to support actions by pediatricians and tobacco smoke. Pediatrics. 2015;136(5): fl 998–1007 diarrhea, chills, uctuations in blood public policy decision makers that can pressure or heart rate, seizures, and reduce the development of tobacco 2. American Academy of Pediatrics increased perspiration and excessive dependence and reduce the tobacco Section on Tobacco Control. Policy 183 salivation. A report using Kentucky smoke exposure of children. statement: clinical practice policy to Regional Poison Control Center protect children from tobacco, nicotine, records in 1991 found 104 cases of LEAD AUTHOR and tobacco smoke. Pediatrics. 2015; 136(5):1008–1017 green tobacco sickness; one-quarter Harold J. Farber, MD, MSPH, FAAP of the reports were in children under Judith A. Groner, MD, FAAP 3. American Academy of Pediatrics 17 years.184 A case series of 5 Steering Committee on Quality children with green tobacco sickness CONTRIBUTING AUTHORS Improvement and Management. reported symptoms that included Kevin E. Nelson, MD, PhD, FAAP Classifying recommendations for a seizure, bradycardia, vomiting, Susan C. Walley, MD, FAAP clinical practice guidelines. Pediatrics. dizziness, headache, pallor, and/or 2004;114(3):874–877 SECTION ON TOBACCO CONTROL, 2015–2016 muscle weakness. One child stated 4. US Department of Health and Human Ruth A. Etzel, MD, PhD, FAAP, Co-chairperson that it made him feel, “like I was going Karen M. Wilson, MD, MPH, FAAP, Co-chairperson Services. Preventing Tobacco Use ”32 to die. Harold J. Farber, MD, MSPH, FAAP, Policy Among Youth and Young Adults: A Chairperson Report of the Surgeon General. Atlanta, 15. Concentrated nicotine solution for Sophie J. Balk, MD, FAAP GA: US Department of Health and electronic nicotine delivery systems Judith A. Groner, MD, FAAP Human Services, Centers for Disease should be sold in child-resistant John E. Moore, MD, FAAP Control and Prevention, National Center containers with amounts limited to that for Chronic Disease Prevention and which would not be lethal to a young STAFF Health Promotion, Office on Smoking child if ingested. Janet Brishke, MPH and Health; 2012 Regina Shaefer, MPH Evidence quality: B 5. Centers for Disease Control and Prevention (CDC). Tobacco product use among middle and high school Recommendation strength: strong ABBREVIATIONS students—United States, 2011 and recommendation ALL: acute lymphoblastic leukemia 2012. MMWR Morb Mortal Wkly Rep. fl – The colorful fruit- and candy- avored CDC: Centers for Disease Control 2013;62(45):893 897 concentrated nicotine solutions for and Prevention 6. Arrazola RA, Kuiper NM, Dube SR. use in electronic nicotine delivery CI: confidence interval Patterns of current use of tobacco systems can appeal to young children. e-cigarette: products among US high school —fi The oral lethal dose of nicotine by FDA: US Food and Drug students for 2000-2012 ndings from body weight that is estimated to kill Administration the National Youth Tobacco Survey. J Adolesc Health. 2014;54(1):54–60.e9 50% of adults is projected to be FTND: Fagerström Test of Nicotine 185 between 0.8 and 13 mg/kg. Severe Dependence 7. Centers for Disease Control and nicotine toxicity in children has been NHANES: National Health and Prevention (CDC). Notes from the field: reported with doses of nicotine as Nutrition Examination electronic cigarette use among middle — low as 2 mg. Calls to poison control Survey and high school students United States, 2011-2012. MMWR Morb Mortal centers for exposures to electronic NYTS: National Youth Tobacco Wkly Rep. 2013;62(35):729–730 nicotine delivery systems (with the Survey majority occurring in children under OR: odds ratio 8. Arrazola RA, Singh T, Corey CG, et al; 5 years) increased from 1 exposure s-ICAM1: soluble intercellular Centers for Disease Control and call per month in September 2010 to adhesion molecule 1 Prevention (CDC). Tobacco use among 186 middle and high school students— 215 calls in February 2014. The SIDS: sudden infant death United States, 2011-2014. MMWR Morb concentrated nicotine solution used syndrome Mortal Wkly Rep. 2015;64(14):381–385 in these devices is a poisoning risk for RSV: respiratory syncytial virus young children, and at least 1 child USPSTF: US Preventive Services 9. Johnston LD, O’Malley PM, Miech RA, has already died of its accidental Task Force Bachman JG, Schulenberg JE. ingestion.187 Monitoring the Future: National Survey

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Downloaded from www.aappublications.org/news by guest on September 29, 2021 Protecting Children From Tobacco, Nicotine, and Tobacco Smoke Harold J. Farber, Judith Groner, Susan Walley, Kevin Nelson and SECTION ON TOBACCO CONTROL Pediatrics 2015;136;e1439 DOI: 10.1542/peds.2015-3110 originally published online October 26, 2015;

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