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Indoor smoking bans associated with fewer ED visits for asthma among children
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Data indicate that legislation against indoor smoking is linked to fewer pediatric ED visits for severe asthma exacerbations among children.
“Although national campaigns have increased awareness of the adverse effects of smoking tobacco, children can still be adversely affected by smoke exposure in restaurants and other public places,” Christina E. Ciaccio, MD, assistant professor of pediatrics at the University of Chicago, and colleagues wrote. “Because medical expenses related to asthma exceed $70 billion a year, the implementation of smoking bans in indoor public spaces has the potential not only to significantly decrease the incidence of asthma exacerbation in children but also lead to an overall significant decrease in the costs associated with this disease by protecting this vulnerable population from this potent asthma trigger.”
To assess the relationship between local and state indoor smoking legislation and severe asthma exacerbations incurring visits to pediatric EDs, the researchers conducted a nationwide retrospective, secondary analysis review of ED visits among children aged 18 years and younger over a 14-year period using the Pediatric Health Information System (PHIS). Further, the researchers used Poisson regression to control for seasonality, age, sex and race/ethnicity in study comparisons both before and after legislation against smoking.
The researchers reviewed 335,588 ED visits among 20 hospitals in 14 states and Washington, D.C. available in PHIS during the study period. Analysis showed that indoor smoking legislation shared a positive correlation with a 17% decrease in childhood ED visits for asthma exacerbation from 3 years prior to legislation through 3 years after legislation (adjusted rate ratio [aRR] = 0.83; 95% CI, 0.82-0.85). Of note, a statistically significant decrease presented after 1 year of legislation (aRR = 0.92; 95% CI, 0.9-0.94) as well as 2 years after legislation (aRR = 0.87; 95% CI, 0.85-0.88).
“After considering 3-year pre- and post-legislation data pooled across 20 geographic locations, we found that indoor smoking legislation was associated with a 17% decrease in the incidence of severe asthma ED visits,” Ciaccio and colleagues wrote. “Significant decreases also occurred within 1- and 2-year time windows. The absolute degree of decrease varied across metropolitan areas.” – by Kate Sherrer
Disclosure: The researchers report no relevant financial disclosures.
Perspective
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Gary S. Rachelefsky, MD
There are some problems with the study: it is retrospective, they are using a database with no control over legislation and number of ED visits; but the researchers collected a great amount of data. I think the message is that it is not causation, but rather an association between municipalities that had laws in place inhibiting indoor smoking in public places.
The problem is that the decrease in ED visits for children experiencing asthma exacerbations could have been a coincidence or how the data was collected. But taking the study at face value, it raises some interesting points. We know that cigarette smoke itself is a trigger of asthma in children, and passive exposure is associated with exacerbations of asthma and worsening asthma. Children who live in homes where parents or caregivers smoke, especially apartments, have asthma more often than children who live with parents or caregivers who do not smoke.
We know that in utero exposure to smoke enhances risk of respiratory disease, so there is a lot of evidence that passive cigarette smoke exposure is harmful to the asthmatic child. These data provide another way of looking at that adverse effect. Also, there is evidence of diminishing ED asthma-related visits for children when there is less cigarette smoke exposure in a public environment. It raises an important point that it is hoped will stimulate more physicians and communities where cigarette smoke is not banned to use this study to enhance more legislation banning the exposure of cigarette smoke for children in general, especially for those who have asthma.
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