Secondhand Smoke Exposure Among High-Risk Patients in the United States (NHANES 2001–2012): Implications for Clinical Practice

Secondhand Smoke Exposure Among High-Risk Patients in the United States (NHANES 2001–2012):... Abstract Introduction Patients with cancer, cardiovascular disease (CVD), and respiratory disease are susceptible to health consequences related to secondhand smoke (SHS) exposure. This study examined the prevalence, time trends, and correlates of SHS exposure among these patients compared with individuals without these diseases (control). Methods Data were obtained from the 2001–2012 National Health and Nutrition Examination Survey. All adults (≥20 years old) who were nonsmokers and exposed to SHS (serum cotinine level 0.015–10 ng/mL), had cancer (n = 1,440), CVD (congestive heart failure, coronary heart disease, angina, heart attack, or stroke; n = 1,754), respiratory disease (asthma, chronic bronchitis, emphysema; n = 1,444), or none of these diseases (control; n = 11,615) were included in the analysis. Weighted prevalence, weighted second-degree polynomial linear regression of prevalence on year for trend analysis, and multivariable logistic regression analyses were performed with adjustments to the complex survey design. Results SHS exposure was the highest among patients with respiratory disease (72.1%), followed by patients with CVD (70.6%), controls (70.4%), and patients with cancer (65.4%). From 2001 to 2012, exposure decreased the most among CVD patients (19.6%), followed by controls (16.0%), cancer patients (14.7%), and respiratory patients (10.0%). Exposed individuals in all groups were more likely to be younger, Black, and less educated. Exposed patients with respiratory disease were more likely to be former smokers (p < .05 for all). Conclusions SHS exposure among these patients is high and comparable to the general population. Strengthening smoke-free policies in all settings is critical. More efforts are needed to address SHS exposure more effectively in clinical care settings. Implications Despite the negative health effect of SHS exposure among patients with cancer, CVD, and respiratory disease, modest progress has been made in reducing their exposure. Continued efforts to strengthen smoke-free policies in workplaces, public place, and multiunit housing is critical. In addition, exposure to SHS among these patients seems to be overlooked in clinical care settings. More efforts are needed to address this problem more effectively in health care settings and investigate specific interventions directed at increasing patients’ awareness about the risk of exposure to SHS and helping them to reducing their exposure. Introduction It is well documented that there is no safe level of exposure to secondhand smoke (SHS).1 Particularly, susceptible groups for health consequences of SHS exposure include patients with cancer, cardiovascular disease (CVD), and respiratory disease who do not smoke. Cancer treatment increases the risk of second cancers, cardiac events, and pulmonary disease, and SHS exposure after cancer diagnosis can exacerbate these complications.2,3 Nonsmokers with lung cancer who are exposed to SHS are 57% more likely to have less 5-year survival rates than those who are not exposed.2 Moreover, evidence suggests that SHS exposure among patients with lung cancer and head and neck cancer jeopardizes smoking cessation efforts placing these patients at risk of active smoking.4,5 SHS exposure among patients with acute coronary syndrome who do not smoke increases the risk of infarction and subsequent cardiovascular and all-cause mortality.6 Finally, in patients who do not smoke and have asthma or chronic obstructive pulmonary disease, SHS exposure aggravates their respiratory symptoms and decreases exercise capacity and quality of life.7 Despite this evidence about the risk of SHS exposure among these patients, national figures regarding the prevalence, time trends, and correlates of SHS exposure have not been investigated in the United States. In this study, we used a nationally representative sample of US adults and relied on serum cotinine level of 0.015–10 ng/mL to indicate exposure to SHS to provide a detailed description of the prevalence, time trends over a period of 12 years (from 2001 to 2012), and correlates of SHS exposure among patients with cancer, CVD, and respiratory diseases compared with individuals without these diseases (control). This information is important to assess the magnitude of the problem of SHS exposure among these groups and guide the development of prevention and intervention strategies to eliminate their exposure to SHS. Methods Data were obtained from the 2001–2012 (six cycles) National Health and Nutrition Examination Survey (NHANES), a complex multistage survey representative of the noninstitutionalized US civilian population, which oversampled persons aged 60 and older, African Americans, Asians, and Hispanics. The survey was administered by household in-person interviews and biologic specimens (including serum cotinine) were collected and tested at a mobile lab center (http://www.cdc.gov/nchs/data/series/sr_01/sr01_056.pdf). Since 1999, the NHANES has been conducted continuously in 2-year cycles. However, only six cycles (2001–2012) were included in the analysis because since 2001, NHANES has used a new more sensitive detectable level of 0.015 ng/mL or greater for serum cotinine, and results of serum cotinine analysis for 2014 and 2016 were still not available at the time of conducting our analysis. Our study sample comprised adults (≥20 years old) who self-reported that they are nonsmokers verified by serum cotinine level less than 10 ng/ml (the cutoff point for active smoking), had cancer, CVD (congestive heart failure, coronary heart disease, angina, heart attack, or stroke), respiratory disease (asthma, chronic bronchitis, emphysema), or none of these diseases (controls). Participants were considered exposed to SHS if their serum cotinine concentration was between 0.015 and 10 ng/mL.8,9 Analyses were conducted using SAS version 9.3 (SAS Institute Inc., Cary, NC), adjusting for sample weights and design effects. We weighted records from each survey year according to person-level weights. Then, we adjusted weights per the number of representative years used in the analyses by dividing the original weight by six, the total number of 2-year survey cycles. We calculated weighted percentages and used weighted second-degree polynomial linear regression of prevalence on year for the trend analysis.10 The model included group, year centered nested within group, and year centered squared nested within group to provide a separate intercepts and slopes analysis. The weight was the inverse of the variance of the prevalence estimate. Planned contrasts were used to compare the regression parameters of cancer, CVD, and respiratory groups with the control group.11 We also conducted a multivariable logistic regression analyses for the four groups with exposure to SHS as the dependent variable. The four models were adjusted to the sociodemographic characteristics variables (age, gender, race/ethnicity, marital status, educational attainment, health insurance, employment status, family poverty index ratio, housing status as a proxy for multiunit housing residence),12 and smoking status (former smoker, never smoker). We reported results using odds ratios and 95% confidence intervals. Interactions between control and each disease groups and the other predictors in the model were tested. Results There were a total of 61951 participants between 2001 and 2012. Among these, 40319 were excluded from the analysis and 21632 were included. Excluded participants were < 20 years old (n = 27796); missing cotinine analysis (n = 2000) and smoking status (n = 28); active smokers (n = 7967); or the weight was ≤ 0 (n = 2528). Among those who were included in the analysis, 15417 were exposed to SHS and 6215 were not exposed. Some of these participants had more than one disease; therefore, they were included in each corresponding disease category yielding an extra 836 cases in the exposed group and 332 cases in the not exposed group. Accordingly, the exposed group included a total of 16253 participants (cancer = 1440; CVD = 1754; respiratory disease = 1444; and controls = 11615), and the not exposed group included a total of 6547 participants (Figure 1). Figure 1. View largeDownload slide The study flow diagram. *Participants who had more than one disease were included in each corresponding disease category yielding an extra 836 cases in the exposed group and 332 cases in the not exposed group. Figure 1. View largeDownload slide The study flow diagram. *Participants who had more than one disease were included in each corresponding disease category yielding an extra 836 cases in the exposed group and 332 cases in the not exposed group. Overall, 70.4% of controls were exposed. Among our high-risk groups, SHS exposure was the highest among patients with respiratory disease (72.1%), followed by patients with CVD (70.6%) and cancer (65.4%). Regarding the time trends in SHS exposure from 2001 to 2012, exposure decreased by 16 percentage points (from 72.4% [95% confidence intervals = 69.9–74.9] to 56.4% [55.3–57.5]) in the control group. Among our high-risk groups, SHS decreased the most among CVD patients by 19.6 percentage points (from 76.7% [64.7–88.6] to 57.1% [47.4–59.1]), followed by cancer patients by 14.7 percentage points (from 67.6% [61.4–73.8] to 52.9% [45.9–60.0]) and respiratory patients 10 percentage points (from 74.1% [57.6–90.6] to 63.3% [45.5–81.1]; Figure 2). The linear portion of the decline in SHS exposure was significant in the control group (−1.60 ± 0.33; p < .001) [parameter ± SE], patients with CVD (−1.96 ± 0.39; p < .001), and patients with cancer (−1.46 ± 0.36; p = .001), but not in patients with respiratory disease (−1.07 ± 0.54; p = .071). There was no significant differences in any of the regression parameters between the control group and any of the disease groups (p value ranged from .06 to .94). Figure 2. View largeDownload slide Trends in secondhand smoke exposure among nonsmoking adults with cancer, cardiovascular disease (CVD), or respiratory disease compared with controls. Data obtained from the 2001–2012 National Health and Nutrition Examination Survey. Figure 2. View largeDownload slide Trends in secondhand smoke exposure among nonsmoking adults with cancer, cardiovascular disease (CVD), or respiratory disease compared with controls. Data obtained from the 2001–2012 National Health and Nutrition Examination Survey. In the multivariable analysis (Table 1), participants who were exposed to SHS in all groups were more likely to be younger, Black, and less educated. Exposed patients with CVD were also more likely to be male, single, and multiunit housing resident than those not exposed. Both exposed patients with cancer and respiratory disease were more likely to be under the poverty level. Exposed patients with respiratory disease were more likely to be former smokers than those not exposed (p < .05 for all). We found no interaction in two groups, cancer and CVD, and two interactions in the respiratory disease group (education [p = .03] and poverty level [p = .02]). The interaction for education and respiratory disease group was congruent (ie, all Adjusted Odds Ratio were in the same direction and significant with the exception of high school vs. less than high school for the respiratory group). The interaction for respiratory disease group and poverty level was also congruent and significant for both groups. As such, the interaction did not affect our results or add any new information. Table 1. Multivariable Logistic Regression Analysis of Exposure to Secondhand Smoke Among Nonsmoking Adulta Who Are Exposedb to Secondhand Smoke and Have Cancerc, CVDd, or Respiratory Diseasee Compared With Controlf (Pooled Data From the 2001–2012 National Health and Nutrition Examination Survey)   Control  Patients at high risk for SHS exposure  Patients with cancer  Patients with CVD  Patients with respiratory disease  OR  (95% CI)  p  OR  (95% CI)  p  OR  (95% CI)  p  OR  (95% CI)  p  Age  0.99  (0.98–1.00)  <.001  0.98  (0.97–1.00)  <.012  0.98  (0.96–0.99)  .002  0.98  (0.97–1.00)  .014  Gender   Female  1.00  —    1.00  —  —  1.00  —  —  1.00  —     Male  1.63  (1.44–1.84)  .001  1.41  (0.95–2.09)  .081  1.46  (1.06–1.99)  .017  1.47  (0.96–2.26)  .073  Education   College  1.00  —    1.00  —    1.00  —    1.00  —     Some college  1.56  (1.34–1.81)  <.001  1.03  (0.70–1.50)  .888  1.47  (1.00–2.17)  .046  1.40  (0.86–2.30)  .171   ≤High school  2.43  (2.06–2.86)  <.001  2.54  (1.70–3.81)  <.0001  2.33  (1.47–3.67)  <.001  4.08  (2.44–6.83)  <.001  Race/ethnicity   Non-Hispanic White  1.00  —  —  1.00  —  —  1.00  —  —  1.00  —  —   Mexican American  0.57  (0.45–0.73)  <.001  0.46  (0.23–0.90)  .022  0.50  (0.24–1.04)  .058  0.33  (0.18–0.58)  <.001   Other Hispanic  0.74  (0.57–0.95)  .018  0.47  (0.24–0.93)  .027  0.40  (0.21–0.74)  .003  0.44  (0.21–0.93)  .028   Non-Hispanic Black  2.21  (1.76–2.78)  <.001  2.42  (1.40–4.17)  .001  2.10  (1.38–3.21)  <.001  1.59  (1.01–2.50)  .041   Other race  1.79  (1.35–2.38)  <.001  2.19  (0.88–5.42)  .085  0.95  (0.47–1.91)  .874  1.37  (0.65–2.88)  .396  Marital status   Married/living with partner  1.00  —  —  1.00  —  —  1.00  —  —  1.00  —  —   Single/divorced/widow  1.37  (1.18–1.59)  <.001  1.11  (0.71–1.74)  .654  1.65  (1.12–2.43)  .010  1.54  (0.90–2.66)  .111   Never married  1.21  (1.01–1.45)  .036  0.91  (0.38–2.21)  .840  0.95  (0.54–1.68)  .861  0.92  (0.47–1.80)  .804  Family poverty index ratio   ≥Poverty level  1.00  —  —  1.00  —  —  1.00  —  —  1.00  —  —   <Poverty level  1.39  (1.14–1.68)  .001  1.99  (1.16–3.44)  .011  1.47  (0.88–2.45)  .130  2.57  (1.59–4.15)  <.001  Employment status   Employed  1.00  —  —  1.00  —  —  1.00  —  —  1.00  —  —   Unemployed  1.29  (1.11–1.50)  .001  1.35  (0.98–1.86)  .060  1.37  (0.83–2.84)  .242  1.35  (0.88–2.08)  .165  Health insurance   Yes  1.00  —  —  1.00  —  —  1.00  —  —  1.00  —  —   No  1.30  (1.02–1.65)  .033  1.36  (0.57–3.23)  .484  1.37  (0.66–2.84)  .385  1.45  (0.88–2.37)  .135  Housing   Own a house  1.00  —  —  1.00  —  —  1.00  —  —  1.00  —  —   Rent a house  1.39  (1.18–1.64)  <.001  1.38  (0.82–2.32)  .212  1.84  (1.25–2.72)  .002  1.64  (0.93–2.90)  .080  Smoking status   Never smoker  1.00  —  —  1.00  —  —  1.00  —  —  1.00  —  —   Former smoker  1.55  (1.31–1.84)  <.001  1.21  (0.88–1.66)  .241  1.38  (0.99–1.91)  .053  1.50  (1.08–2.10)  .015    Control  Patients at high risk for SHS exposure  Patients with cancer  Patients with CVD  Patients with respiratory disease  OR  (95% CI)  p  OR  (95% CI)  p  OR  (95% CI)  p  OR  (95% CI)  p  Age  0.99  (0.98–1.00)  <.001  0.98  (0.97–1.00)  <.012  0.98  (0.96–0.99)  .002  0.98  (0.97–1.00)  .014  Gender   Female  1.00  —    1.00  —  —  1.00  —  —  1.00  —     Male  1.63  (1.44–1.84)  .001  1.41  (0.95–2.09)  .081  1.46  (1.06–1.99)  .017  1.47  (0.96–2.26)  .073  Education   College  1.00  —    1.00  —    1.00  —    1.00  —     Some college  1.56  (1.34–1.81)  <.001  1.03  (0.70–1.50)  .888  1.47  (1.00–2.17)  .046  1.40  (0.86–2.30)  .171   ≤High school  2.43  (2.06–2.86)  <.001  2.54  (1.70–3.81)  <.0001  2.33  (1.47–3.67)  <.001  4.08  (2.44–6.83)  <.001  Race/ethnicity   Non-Hispanic White  1.00  —  —  1.00  —  —  1.00  —  —  1.00  —  —   Mexican American  0.57  (0.45–0.73)  <.001  0.46  (0.23–0.90)  .022  0.50  (0.24–1.04)  .058  0.33  (0.18–0.58)  <.001   Other Hispanic  0.74  (0.57–0.95)  .018  0.47  (0.24–0.93)  .027  0.40  (0.21–0.74)  .003  0.44  (0.21–0.93)  .028   Non-Hispanic Black  2.21  (1.76–2.78)  <.001  2.42  (1.40–4.17)  .001  2.10  (1.38–3.21)  <.001  1.59  (1.01–2.50)  .041   Other race  1.79  (1.35–2.38)  <.001  2.19  (0.88–5.42)  .085  0.95  (0.47–1.91)  .874  1.37  (0.65–2.88)  .396  Marital status   Married/living with partner  1.00  —  —  1.00  —  —  1.00  —  —  1.00  —  —   Single/divorced/widow  1.37  (1.18–1.59)  <.001  1.11  (0.71–1.74)  .654  1.65  (1.12–2.43)  .010  1.54  (0.90–2.66)  .111   Never married  1.21  (1.01–1.45)  .036  0.91  (0.38–2.21)  .840  0.95  (0.54–1.68)  .861  0.92  (0.47–1.80)  .804  Family poverty index ratio   ≥Poverty level  1.00  —  —  1.00  —  —  1.00  —  —  1.00  —  —   <Poverty level  1.39  (1.14–1.68)  .001  1.99  (1.16–3.44)  .011  1.47  (0.88–2.45)  .130  2.57  (1.59–4.15)  <.001  Employment status   Employed  1.00  —  —  1.00  —  —  1.00  —  —  1.00  —  —   Unemployed  1.29  (1.11–1.50)  .001  1.35  (0.98–1.86)  .060  1.37  (0.83–2.84)  .242  1.35  (0.88–2.08)  .165  Health insurance   Yes  1.00  —  —  1.00  —  —  1.00  —  —  1.00  —  —   No  1.30  (1.02–1.65)  .033  1.36  (0.57–3.23)  .484  1.37  (0.66–2.84)  .385  1.45  (0.88–2.37)  .135  Housing   Own a house  1.00  —  —  1.00  —  —  1.00  —  —  1.00  —  —   Rent a house  1.39  (1.18–1.64)  <.001  1.38  (0.82–2.32)  .212  1.84  (1.25–2.72)  .002  1.64  (0.93–2.90)  .080  Smoking status   Never smoker  1.00  —  —  1.00  —  —  1.00  —  —  1.00  —  —   Former smoker  1.55  (1.31–1.84)  <.001  1.21  (0.88–1.66)  .241  1.38  (0.99–1.91)  .053  1.50  (1.08–2.10)  .015  Bolded values signify statistically significant findings at p < .05 level. CI, confidence interval; CVD, cardiovascular disease; OR, odds ratio; SHS, secondhand smoke. aNonsmoking adults who had a serum cotinine level of <10 ng/mL (the threshold for not being active smoker). bBased on serum cotinine level of 0.015–10 ng/mL. cPatients with cancer: Ever been told by a doctor or other health professional that they had cancer or a malignancy of any kind. dPatients with CVD: Ever been told by a doctor or other health professional that they had congestive heart failure, coronary heart disease, angina, heart attack, or stroke. ePatient with respiratory disease: Ever been told by a doctor or other health professional that they had asthma, chronic bronchitis, or emphysema. fNonsmoking adults without cancer, CVD, or respiratory disease. View Large Table 1. Multivariable Logistic Regression Analysis of Exposure to Secondhand Smoke Among Nonsmoking Adulta Who Are Exposedb to Secondhand Smoke and Have Cancerc, CVDd, or Respiratory Diseasee Compared With Controlf (Pooled Data From the 2001–2012 National Health and Nutrition Examination Survey)   Control  Patients at high risk for SHS exposure  Patients with cancer  Patients with CVD  Patients with respiratory disease  OR  (95% CI)  p  OR  (95% CI)  p  OR  (95% CI)  p  OR  (95% CI)  p  Age  0.99  (0.98–1.00)  <.001  0.98  (0.97–1.00)  <.012  0.98  (0.96–0.99)  .002  0.98  (0.97–1.00)  .014  Gender   Female  1.00  —    1.00  —  —  1.00  —  —  1.00  —     Male  1.63  (1.44–1.84)  .001  1.41  (0.95–2.09)  .081  1.46  (1.06–1.99)  .017  1.47  (0.96–2.26)  .073  Education   College  1.00  —    1.00  —    1.00  —    1.00  —     Some college  1.56  (1.34–1.81)  <.001  1.03  (0.70–1.50)  .888  1.47  (1.00–2.17)  .046  1.40  (0.86–2.30)  .171   ≤High school  2.43  (2.06–2.86)  <.001  2.54  (1.70–3.81)  <.0001  2.33  (1.47–3.67)  <.001  4.08  (2.44–6.83)  <.001  Race/ethnicity   Non-Hispanic White  1.00  —  —  1.00  —  —  1.00  —  —  1.00  —  —   Mexican American  0.57  (0.45–0.73)  <.001  0.46  (0.23–0.90)  .022  0.50  (0.24–1.04)  .058  0.33  (0.18–0.58)  <.001   Other Hispanic  0.74  (0.57–0.95)  .018  0.47  (0.24–0.93)  .027  0.40  (0.21–0.74)  .003  0.44  (0.21–0.93)  .028   Non-Hispanic Black  2.21  (1.76–2.78)  <.001  2.42  (1.40–4.17)  .001  2.10  (1.38–3.21)  <.001  1.59  (1.01–2.50)  .041   Other race  1.79  (1.35–2.38)  <.001  2.19  (0.88–5.42)  .085  0.95  (0.47–1.91)  .874  1.37  (0.65–2.88)  .396  Marital status   Married/living with partner  1.00  —  —  1.00  —  —  1.00  —  —  1.00  —  —   Single/divorced/widow  1.37  (1.18–1.59)  <.001  1.11  (0.71–1.74)  .654  1.65  (1.12–2.43)  .010  1.54  (0.90–2.66)  .111   Never married  1.21  (1.01–1.45)  .036  0.91  (0.38–2.21)  .840  0.95  (0.54–1.68)  .861  0.92  (0.47–1.80)  .804  Family poverty index ratio   ≥Poverty level  1.00  —  —  1.00  —  —  1.00  —  —  1.00  —  —   <Poverty level  1.39  (1.14–1.68)  .001  1.99  (1.16–3.44)  .011  1.47  (0.88–2.45)  .130  2.57  (1.59–4.15)  <.001  Employment status   Employed  1.00  —  —  1.00  —  —  1.00  —  —  1.00  —  —   Unemployed  1.29  (1.11–1.50)  .001  1.35  (0.98–1.86)  .060  1.37  (0.83–2.84)  .242  1.35  (0.88–2.08)  .165  Health insurance   Yes  1.00  —  —  1.00  —  —  1.00  —  —  1.00  —  —   No  1.30  (1.02–1.65)  .033  1.36  (0.57–3.23)  .484  1.37  (0.66–2.84)  .385  1.45  (0.88–2.37)  .135  Housing   Own a house  1.00  —  —  1.00  —  —  1.00  —  —  1.00  —  —   Rent a house  1.39  (1.18–1.64)  <.001  1.38  (0.82–2.32)  .212  1.84  (1.25–2.72)  .002  1.64  (0.93–2.90)  .080  Smoking status   Never smoker  1.00  —  —  1.00  —  —  1.00  —  —  1.00  —  —   Former smoker  1.55  (1.31–1.84)  <.001  1.21  (0.88–1.66)  .241  1.38  (0.99–1.91)  .053  1.50  (1.08–2.10)  .015    Control  Patients at high risk for SHS exposure  Patients with cancer  Patients with CVD  Patients with respiratory disease  OR  (95% CI)  p  OR  (95% CI)  p  OR  (95% CI)  p  OR  (95% CI)  p  Age  0.99  (0.98–1.00)  <.001  0.98  (0.97–1.00)  <.012  0.98  (0.96–0.99)  .002  0.98  (0.97–1.00)  .014  Gender   Female  1.00  —    1.00  —  —  1.00  —  —  1.00  —     Male  1.63  (1.44–1.84)  .001  1.41  (0.95–2.09)  .081  1.46  (1.06–1.99)  .017  1.47  (0.96–2.26)  .073  Education   College  1.00  —    1.00  —    1.00  —    1.00  —     Some college  1.56  (1.34–1.81)  <.001  1.03  (0.70–1.50)  .888  1.47  (1.00–2.17)  .046  1.40  (0.86–2.30)  .171   ≤High school  2.43  (2.06–2.86)  <.001  2.54  (1.70–3.81)  <.0001  2.33  (1.47–3.67)  <.001  4.08  (2.44–6.83)  <.001  Race/ethnicity   Non-Hispanic White  1.00  —  —  1.00  —  —  1.00  —  —  1.00  —  —   Mexican American  0.57  (0.45–0.73)  <.001  0.46  (0.23–0.90)  .022  0.50  (0.24–1.04)  .058  0.33  (0.18–0.58)  <.001   Other Hispanic  0.74  (0.57–0.95)  .018  0.47  (0.24–0.93)  .027  0.40  (0.21–0.74)  .003  0.44  (0.21–0.93)  .028   Non-Hispanic Black  2.21  (1.76–2.78)  <.001  2.42  (1.40–4.17)  .001  2.10  (1.38–3.21)  <.001  1.59  (1.01–2.50)  .041   Other race  1.79  (1.35–2.38)  <.001  2.19  (0.88–5.42)  .085  0.95  (0.47–1.91)  .874  1.37  (0.65–2.88)  .396  Marital status   Married/living with partner  1.00  —  —  1.00  —  —  1.00  —  —  1.00  —  —   Single/divorced/widow  1.37  (1.18–1.59)  <.001  1.11  (0.71–1.74)  .654  1.65  (1.12–2.43)  .010  1.54  (0.90–2.66)  .111   Never married  1.21  (1.01–1.45)  .036  0.91  (0.38–2.21)  .840  0.95  (0.54–1.68)  .861  0.92  (0.47–1.80)  .804  Family poverty index ratio   ≥Poverty level  1.00  —  —  1.00  —  —  1.00  —  —  1.00  —  —   <Poverty level  1.39  (1.14–1.68)  .001  1.99  (1.16–3.44)  .011  1.47  (0.88–2.45)  .130  2.57  (1.59–4.15)  <.001  Employment status   Employed  1.00  —  —  1.00  —  —  1.00  —  —  1.00  —  —   Unemployed  1.29  (1.11–1.50)  .001  1.35  (0.98–1.86)  .060  1.37  (0.83–2.84)  .242  1.35  (0.88–2.08)  .165  Health insurance   Yes  1.00  —  —  1.00  —  —  1.00  —  —  1.00  —  —   No  1.30  (1.02–1.65)  .033  1.36  (0.57–3.23)  .484  1.37  (0.66–2.84)  .385  1.45  (0.88–2.37)  .135  Housing   Own a house  1.00  —  —  1.00  —  —  1.00  —  —  1.00  —  —   Rent a house  1.39  (1.18–1.64)  <.001  1.38  (0.82–2.32)  .212  1.84  (1.25–2.72)  .002  1.64  (0.93–2.90)  .080  Smoking status   Never smoker  1.00  —  —  1.00  —  —  1.00  —  —  1.00  —  —   Former smoker  1.55  (1.31–1.84)  <.001  1.21  (0.88–1.66)  .241  1.38  (0.99–1.91)  .053  1.50  (1.08–2.10)  .015  Bolded values signify statistically significant findings at p < .05 level. CI, confidence interval; CVD, cardiovascular disease; OR, odds ratio; SHS, secondhand smoke. aNonsmoking adults who had a serum cotinine level of <10 ng/mL (the threshold for not being active smoker). bBased on serum cotinine level of 0.015–10 ng/mL. cPatients with cancer: Ever been told by a doctor or other health professional that they had cancer or a malignancy of any kind. dPatients with CVD: Ever been told by a doctor or other health professional that they had congestive heart failure, coronary heart disease, angina, heart attack, or stroke. ePatient with respiratory disease: Ever been told by a doctor or other health professional that they had asthma, chronic bronchitis, or emphysema. fNonsmoking adults without cancer, CVD, or respiratory disease. View Large Discussion This is the first study to describe the prevalence, time trends, and correlates of SHS exposure verified by serum cotinine analysis among a nationally representative sample of nonsmoking patients with cancer, CVD, or respiratory disease in the United States compared with individuals without these diseases (control group). Consistent with prior studies, our findings confirm that SHS exposure among these patients is very common and its decline is comparable to the general population,13–15 with the highest prevalence and least decline among patients with respiratory diseases. Finally, similar to the control group, disparities in exposure persist among these patients with the youngest, non-Hispanic Black, and less educated being among the most exposed. Strengthening smoke-free policies in workplaces, public place, and multiunit housing is critical. SHS exposure among these patients seems to be overlooked in clinical settings, particularly among patients with respiratory disease. Efforts are needed to address SHS exposure more effectively in clinical settings to increase patients’ awareness about the risk of exposure to SHS and help them reducing their exposure. Our study is the first to examine SHS exposure prevalence time trends in patients with cancer, CVD, and respiratory disease in the United States. Our findings show that over 12 years, the decline in SHS exposure was the most in CVD patients, and the least in patients with respiratory disease, and the difference in the decline between the control group and any of the disease groups was not significant. Of note, the decline in our control group was consistent and comparable with prior studies based on NHANES data.12 However, it is important to mention that SHS exposure prevalence in these studies were lower than our study (eg, 25.3% vs. 56.6% in 2012) because they used the old cutpoint of detection for serum cotinine less than 0.05 ng/mL, while we used the more sensitive new cut point of 0.015 ng/mL that has been the standard cut point in NHANES data since 2001 because of improvements in the method. Therefore, despite the decline in SHS exposure, a noteworthy proportion of our high-risk groups are still exposed to SHS, making the reduction in SHS exposure an important public health problem in the United States that requires more attention. In the United States, only few studies to date have evaluated exposure to SHS among these patient groups and tried to explore patients’ beliefs and clinicians’ action about SHS exposure. In a study investigating SHS exposure among hospitalized nonsmokers with CVD found that although 40.3% of these patients had detectable levels of a biomarker of SHS exposure, they were rarely screened for SHS exposure (17.3%) or advised to avoid it (1.4%).15 We found only two studies developed and tested a clinical-based interventions to eliminate SHS exposure among patients. Conducted in 2010, the first study developed and tested the effectiveness of a system-level nurse-delivered intervention implemented in two inpatient cardiac units in Boston, MA.16 The intervention was a system-level change in nurses’ workflow for admitting patients that added to the admission form a question assessing patients’ SHS exposure “Does anyone ever smoke in your home or car?”, a statement of advice to be read to all patients “In order to keep your heart healthy, you need to keep your home and car smoke free,” and a prompt reminding nurses to distribute a pamphlet about SHS exposure “Give the patient the smoke-free home pamphlet.” The intervention was evaluated among 352 nonsmokers hospitalized with coronary heart disease and proved to be effective in changing awareness and knowledge. Postintervention patients were more likely to recall being asked if a household member smokes, advised to keep their home and car smoke-free, and aware that SHS exposure is harmful. In the second study, investigators demonstrated the feasibility of implementing the same intervention in a general hospital.17 Similar attempts among cancer and respiratory patients do not yet exist. This study is limited by the cross-sectional design of NHANES, which prevents us from making causal inferences. Second, the cut points of serum cotinine can biologically vary by race/ethnicity and age.18,19 However, using a highly sensitive cut point of cotinine level (0.015 ng/mL) to determine exposure increases our ability to biologically detect SHS exposure.18 Despite these limitations, this report presents unique, nationally representative findings about a serious public health problem in the United States. In conclusion, our results indicate that modest progress has been made in reducing SHS exposure among patients at high risk for SHS exposure in the United States. Continued efforts to strengthen smoke-free policies in all settings are needed. Health care systems are missing an important opportunity to identify and intervene in this major modifiable risk factor, which could be lifesaving. The present study emphasizes the need to address this problem more effectively in health care settings and investigate specific interventions directed at the reduction in SHS exposure among these patients. Funding Funding for this study was provided in part by the Bankhead Coley Cancer Research grant 1BG06-341963 (P.I., DJL) and Flight Attendant Medical Research Institute (FAMRI) Clinical Innovator Award (#103006_CIA; P.I., TK-S). Declaration of Interests The coauthors and I wish to express that we have no financial or other relationships that might lead to a conflict of interest. In addition, we all have participated in the conception of this report and have assisted in revising the manuscript for important intellectual content; last, we have provided final approval of the enclosed report. Acknowledgments TA and KA were responsible for the study concept and design. KA conducted the statistical analyses. TA wrote the first draft of the manuscript, and all authors participated in critically revising and editing the manuscript. All authors contributed to and had approved the final manuscript. References 1. USDHHS. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General . Atlanta, GA: USDHHS, CDC, COCHP, NCCDPHP, OSH; 2006: 709. 2. Zhou W, Heist RS, Liu G, et al.   Second hand smoke exposure and survival in early-stage non-small-cell lung cancer patients. Clin Cancer Res . 2006; 12( 23): 7187– 7193. Google Scholar CrossRef Search ADS PubMed  3. Yeh ET, Bickford CL. Cardiovascular complications of cancer therapy: incidence, pathogenesis, diagnosis, and management. J Am Coll Cardiol . 2009; 53( 24): 2231– 2247. Google Scholar CrossRef Search ADS PubMed  4. Eng L, Qiu X, Su J, et al.   The role of second-hand smoke exposure on smoking cessation in non-tobacco-related cancers. Cancer . 2015; 121( 15): 2655– 2663. Google Scholar CrossRef Search ADS PubMed  5. Kashigar A, Habbous S, Eng L, et al.   Social environment, secondary smoking exposure, and smoking cessation among head and neck cancer patients. Cancer . 2013; 119( 15): 2701– 2709. Google Scholar CrossRef Search ADS PubMed  6. Raupach T, Schäfer K, Konstantinides S, Andreas S. Secondhand smoke as an acute threat for the cardiovascular system: a change in paradigm. Eur Heart J . 2006; 27( 4): 386– 392. Google Scholar CrossRef Search ADS PubMed  7. Putcha N, Crainiceanu C, Norato G, et al.   Influence of lung function and sleep-disordered breathing on all-cause mortality. A community-based study. Am J Respir Crit Care Med . 2016; 194( 8): 1007– 1014. Google Scholar CrossRef Search ADS PubMed  8. Crinnion WJ. The CDC fourth national report on human exposure to environmental chemicals: what it tells us about our toxic burden and how it assist environmental medicine physicians. Altern Med Rev . 2010; 15( 2): 101– 109. Google Scholar PubMed  9. Pirkle JL, Bernert JT, Caudill SP, Sosnoff CS, Pechacek TF. Trends in the exposure of nonsmokers in the U.S. population to secondhand smoke: 1988–2002. Environ Health Perspect . 2006; 114( 6): 853– 858. Google Scholar CrossRef Search ADS PubMed  10. Fan J, Heckman NE, Wand MP. Local polynomial kernel regression for generalized linear models and quasi-likelihood functions. J Am Stat Assoc . 1995; 90( 429): 141– 150. Google Scholar CrossRef Search ADS   11. McCullagh P. Generalized linear models. Eur J Oper Res . 1984; 16( 3): 285– 292. Google Scholar CrossRef Search ADS   12. Homa DM, Neff LJ, King BA, et al.  ; Centers for Disease Control and Prevention (CDC). Vital signs: disparities in nonsmokers’ exposure to secondhand smoke – United States, 1999–2012. MMWR Morb Mortal Wkly Rep . 2015; 64( 4): 103– 108. Google Scholar PubMed  13. Clawson AH, Nicholson JS, McDermott MJ, Klosky JL, Tyc VL. Tobacco use and exposure among youth undergoing cancer treatment. J Pediatr Health Care . 2015; 29( 1): 80– 87. Google Scholar CrossRef Search ADS PubMed  14. Eng L, Su J, Qiu X, et al.   Second-hand smoke as a predictor of smoking cessation among lung cancer survivors. J Clin Oncol . 2014; 32( 6): 564– 570. Google Scholar CrossRef Search ADS PubMed  15. Japuntich SJ, Eilers MA, Shenhav S, et al.   Secondhand tobacco smoke exposure among hospitalized nonsmokers with coronary heart disease. JAMA Intern Med . 2015; 175( 1): 133– 136. Google Scholar CrossRef Search ADS PubMed  16. Rigotti NA, Park ER, Streck J, et al.   An intervention to address secondhand tobacco smoke exposure among nonsmokers hospitalized with coronary heart disease. Am J Cardiol . 2014; 114( 7): 1040– 1045. Google Scholar CrossRef Search ADS PubMed  17. Kruse GR, Rigotti NA. Routine screening of hospital patients for secondhand tobacco smoke exposure: a feasibility study. Prev Med . 2014; 69(1): 141– 145. Google Scholar CrossRef Search ADS   18. Centers for Disease Control and Prevention (CDC). Vital signs: nonsmokers’ exposure to secondhand smoke – United States, 1999–2008. MMWR Morb Mortal Wkly Rep . 2010; 59( 35): 1141. PubMed  19. Benowitz NL, Bernert JT, Caraballo RS, Holiday DB, Wang J. Optimal serum cotinine levels for distinguishing cigarette smokers and nonsmokers within different racial/ethnic groups in the United States between 1999 and 2004. Am. J. Epidemiol . 2009; 169( 2): 236– 248. Google Scholar CrossRef Search ADS PubMed  © The Author(s) 2018. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Nicotine and Tobacco Research Oxford University Press

Secondhand Smoke Exposure Among High-Risk Patients in the United States (NHANES 2001–2012): Implications for Clinical Practice

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© The Author(s) 2018. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.
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1462-2203
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10.1093/ntr/nty060
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Abstract

Abstract Introduction Patients with cancer, cardiovascular disease (CVD), and respiratory disease are susceptible to health consequences related to secondhand smoke (SHS) exposure. This study examined the prevalence, time trends, and correlates of SHS exposure among these patients compared with individuals without these diseases (control). Methods Data were obtained from the 2001–2012 National Health and Nutrition Examination Survey. All adults (≥20 years old) who were nonsmokers and exposed to SHS (serum cotinine level 0.015–10 ng/mL), had cancer (n = 1,440), CVD (congestive heart failure, coronary heart disease, angina, heart attack, or stroke; n = 1,754), respiratory disease (asthma, chronic bronchitis, emphysema; n = 1,444), or none of these diseases (control; n = 11,615) were included in the analysis. Weighted prevalence, weighted second-degree polynomial linear regression of prevalence on year for trend analysis, and multivariable logistic regression analyses were performed with adjustments to the complex survey design. Results SHS exposure was the highest among patients with respiratory disease (72.1%), followed by patients with CVD (70.6%), controls (70.4%), and patients with cancer (65.4%). From 2001 to 2012, exposure decreased the most among CVD patients (19.6%), followed by controls (16.0%), cancer patients (14.7%), and respiratory patients (10.0%). Exposed individuals in all groups were more likely to be younger, Black, and less educated. Exposed patients with respiratory disease were more likely to be former smokers (p < .05 for all). Conclusions SHS exposure among these patients is high and comparable to the general population. Strengthening smoke-free policies in all settings is critical. More efforts are needed to address SHS exposure more effectively in clinical care settings. Implications Despite the negative health effect of SHS exposure among patients with cancer, CVD, and respiratory disease, modest progress has been made in reducing their exposure. Continued efforts to strengthen smoke-free policies in workplaces, public place, and multiunit housing is critical. In addition, exposure to SHS among these patients seems to be overlooked in clinical care settings. More efforts are needed to address this problem more effectively in health care settings and investigate specific interventions directed at increasing patients’ awareness about the risk of exposure to SHS and helping them to reducing their exposure. Introduction It is well documented that there is no safe level of exposure to secondhand smoke (SHS).1 Particularly, susceptible groups for health consequences of SHS exposure include patients with cancer, cardiovascular disease (CVD), and respiratory disease who do not smoke. Cancer treatment increases the risk of second cancers, cardiac events, and pulmonary disease, and SHS exposure after cancer diagnosis can exacerbate these complications.2,3 Nonsmokers with lung cancer who are exposed to SHS are 57% more likely to have less 5-year survival rates than those who are not exposed.2 Moreover, evidence suggests that SHS exposure among patients with lung cancer and head and neck cancer jeopardizes smoking cessation efforts placing these patients at risk of active smoking.4,5 SHS exposure among patients with acute coronary syndrome who do not smoke increases the risk of infarction and subsequent cardiovascular and all-cause mortality.6 Finally, in patients who do not smoke and have asthma or chronic obstructive pulmonary disease, SHS exposure aggravates their respiratory symptoms and decreases exercise capacity and quality of life.7 Despite this evidence about the risk of SHS exposure among these patients, national figures regarding the prevalence, time trends, and correlates of SHS exposure have not been investigated in the United States. In this study, we used a nationally representative sample of US adults and relied on serum cotinine level of 0.015–10 ng/mL to indicate exposure to SHS to provide a detailed description of the prevalence, time trends over a period of 12 years (from 2001 to 2012), and correlates of SHS exposure among patients with cancer, CVD, and respiratory diseases compared with individuals without these diseases (control). This information is important to assess the magnitude of the problem of SHS exposure among these groups and guide the development of prevention and intervention strategies to eliminate their exposure to SHS. Methods Data were obtained from the 2001–2012 (six cycles) National Health and Nutrition Examination Survey (NHANES), a complex multistage survey representative of the noninstitutionalized US civilian population, which oversampled persons aged 60 and older, African Americans, Asians, and Hispanics. The survey was administered by household in-person interviews and biologic specimens (including serum cotinine) were collected and tested at a mobile lab center (http://www.cdc.gov/nchs/data/series/sr_01/sr01_056.pdf). Since 1999, the NHANES has been conducted continuously in 2-year cycles. However, only six cycles (2001–2012) were included in the analysis because since 2001, NHANES has used a new more sensitive detectable level of 0.015 ng/mL or greater for serum cotinine, and results of serum cotinine analysis for 2014 and 2016 were still not available at the time of conducting our analysis. Our study sample comprised adults (≥20 years old) who self-reported that they are nonsmokers verified by serum cotinine level less than 10 ng/ml (the cutoff point for active smoking), had cancer, CVD (congestive heart failure, coronary heart disease, angina, heart attack, or stroke), respiratory disease (asthma, chronic bronchitis, emphysema), or none of these diseases (controls). Participants were considered exposed to SHS if their serum cotinine concentration was between 0.015 and 10 ng/mL.8,9 Analyses were conducted using SAS version 9.3 (SAS Institute Inc., Cary, NC), adjusting for sample weights and design effects. We weighted records from each survey year according to person-level weights. Then, we adjusted weights per the number of representative years used in the analyses by dividing the original weight by six, the total number of 2-year survey cycles. We calculated weighted percentages and used weighted second-degree polynomial linear regression of prevalence on year for the trend analysis.10 The model included group, year centered nested within group, and year centered squared nested within group to provide a separate intercepts and slopes analysis. The weight was the inverse of the variance of the prevalence estimate. Planned contrasts were used to compare the regression parameters of cancer, CVD, and respiratory groups with the control group.11 We also conducted a multivariable logistic regression analyses for the four groups with exposure to SHS as the dependent variable. The four models were adjusted to the sociodemographic characteristics variables (age, gender, race/ethnicity, marital status, educational attainment, health insurance, employment status, family poverty index ratio, housing status as a proxy for multiunit housing residence),12 and smoking status (former smoker, never smoker). We reported results using odds ratios and 95% confidence intervals. Interactions between control and each disease groups and the other predictors in the model were tested. Results There were a total of 61951 participants between 2001 and 2012. Among these, 40319 were excluded from the analysis and 21632 were included. Excluded participants were < 20 years old (n = 27796); missing cotinine analysis (n = 2000) and smoking status (n = 28); active smokers (n = 7967); or the weight was ≤ 0 (n = 2528). Among those who were included in the analysis, 15417 were exposed to SHS and 6215 were not exposed. Some of these participants had more than one disease; therefore, they were included in each corresponding disease category yielding an extra 836 cases in the exposed group and 332 cases in the not exposed group. Accordingly, the exposed group included a total of 16253 participants (cancer = 1440; CVD = 1754; respiratory disease = 1444; and controls = 11615), and the not exposed group included a total of 6547 participants (Figure 1). Figure 1. View largeDownload slide The study flow diagram. *Participants who had more than one disease were included in each corresponding disease category yielding an extra 836 cases in the exposed group and 332 cases in the not exposed group. Figure 1. View largeDownload slide The study flow diagram. *Participants who had more than one disease were included in each corresponding disease category yielding an extra 836 cases in the exposed group and 332 cases in the not exposed group. Overall, 70.4% of controls were exposed. Among our high-risk groups, SHS exposure was the highest among patients with respiratory disease (72.1%), followed by patients with CVD (70.6%) and cancer (65.4%). Regarding the time trends in SHS exposure from 2001 to 2012, exposure decreased by 16 percentage points (from 72.4% [95% confidence intervals = 69.9–74.9] to 56.4% [55.3–57.5]) in the control group. Among our high-risk groups, SHS decreased the most among CVD patients by 19.6 percentage points (from 76.7% [64.7–88.6] to 57.1% [47.4–59.1]), followed by cancer patients by 14.7 percentage points (from 67.6% [61.4–73.8] to 52.9% [45.9–60.0]) and respiratory patients 10 percentage points (from 74.1% [57.6–90.6] to 63.3% [45.5–81.1]; Figure 2). The linear portion of the decline in SHS exposure was significant in the control group (−1.60 ± 0.33; p < .001) [parameter ± SE], patients with CVD (−1.96 ± 0.39; p < .001), and patients with cancer (−1.46 ± 0.36; p = .001), but not in patients with respiratory disease (−1.07 ± 0.54; p = .071). There was no significant differences in any of the regression parameters between the control group and any of the disease groups (p value ranged from .06 to .94). Figure 2. View largeDownload slide Trends in secondhand smoke exposure among nonsmoking adults with cancer, cardiovascular disease (CVD), or respiratory disease compared with controls. Data obtained from the 2001–2012 National Health and Nutrition Examination Survey. Figure 2. View largeDownload slide Trends in secondhand smoke exposure among nonsmoking adults with cancer, cardiovascular disease (CVD), or respiratory disease compared with controls. Data obtained from the 2001–2012 National Health and Nutrition Examination Survey. In the multivariable analysis (Table 1), participants who were exposed to SHS in all groups were more likely to be younger, Black, and less educated. Exposed patients with CVD were also more likely to be male, single, and multiunit housing resident than those not exposed. Both exposed patients with cancer and respiratory disease were more likely to be under the poverty level. Exposed patients with respiratory disease were more likely to be former smokers than those not exposed (p < .05 for all). We found no interaction in two groups, cancer and CVD, and two interactions in the respiratory disease group (education [p = .03] and poverty level [p = .02]). The interaction for education and respiratory disease group was congruent (ie, all Adjusted Odds Ratio were in the same direction and significant with the exception of high school vs. less than high school for the respiratory group). The interaction for respiratory disease group and poverty level was also congruent and significant for both groups. As such, the interaction did not affect our results or add any new information. Table 1. Multivariable Logistic Regression Analysis of Exposure to Secondhand Smoke Among Nonsmoking Adulta Who Are Exposedb to Secondhand Smoke and Have Cancerc, CVDd, or Respiratory Diseasee Compared With Controlf (Pooled Data From the 2001–2012 National Health and Nutrition Examination Survey)   Control  Patients at high risk for SHS exposure  Patients with cancer  Patients with CVD  Patients with respiratory disease  OR  (95% CI)  p  OR  (95% CI)  p  OR  (95% CI)  p  OR  (95% CI)  p  Age  0.99  (0.98–1.00)  <.001  0.98  (0.97–1.00)  <.012  0.98  (0.96–0.99)  .002  0.98  (0.97–1.00)  .014  Gender   Female  1.00  —    1.00  —  —  1.00  —  —  1.00  —     Male  1.63  (1.44–1.84)  .001  1.41  (0.95–2.09)  .081  1.46  (1.06–1.99)  .017  1.47  (0.96–2.26)  .073  Education   College  1.00  —    1.00  —    1.00  —    1.00  —     Some college  1.56  (1.34–1.81)  <.001  1.03  (0.70–1.50)  .888  1.47  (1.00–2.17)  .046  1.40  (0.86–2.30)  .171   ≤High school  2.43  (2.06–2.86)  <.001  2.54  (1.70–3.81)  <.0001  2.33  (1.47–3.67)  <.001  4.08  (2.44–6.83)  <.001  Race/ethnicity   Non-Hispanic White  1.00  —  —  1.00  —  —  1.00  —  —  1.00  —  —   Mexican American  0.57  (0.45–0.73)  <.001  0.46  (0.23–0.90)  .022  0.50  (0.24–1.04)  .058  0.33  (0.18–0.58)  <.001   Other Hispanic  0.74  (0.57–0.95)  .018  0.47  (0.24–0.93)  .027  0.40  (0.21–0.74)  .003  0.44  (0.21–0.93)  .028   Non-Hispanic Black  2.21  (1.76–2.78)  <.001  2.42  (1.40–4.17)  .001  2.10  (1.38–3.21)  <.001  1.59  (1.01–2.50)  .041   Other race  1.79  (1.35–2.38)  <.001  2.19  (0.88–5.42)  .085  0.95  (0.47–1.91)  .874  1.37  (0.65–2.88)  .396  Marital status   Married/living with partner  1.00  —  —  1.00  —  —  1.00  —  —  1.00  —  —   Single/divorced/widow  1.37  (1.18–1.59)  <.001  1.11  (0.71–1.74)  .654  1.65  (1.12–2.43)  .010  1.54  (0.90–2.66)  .111   Never married  1.21  (1.01–1.45)  .036  0.91  (0.38–2.21)  .840  0.95  (0.54–1.68)  .861  0.92  (0.47–1.80)  .804  Family poverty index ratio   ≥Poverty level  1.00  —  —  1.00  —  —  1.00  —  —  1.00  —  —   <Poverty level  1.39  (1.14–1.68)  .001  1.99  (1.16–3.44)  .011  1.47  (0.88–2.45)  .130  2.57  (1.59–4.15)  <.001  Employment status   Employed  1.00  —  —  1.00  —  —  1.00  —  —  1.00  —  —   Unemployed  1.29  (1.11–1.50)  .001  1.35  (0.98–1.86)  .060  1.37  (0.83–2.84)  .242  1.35  (0.88–2.08)  .165  Health insurance   Yes  1.00  —  —  1.00  —  —  1.00  —  —  1.00  —  —   No  1.30  (1.02–1.65)  .033  1.36  (0.57–3.23)  .484  1.37  (0.66–2.84)  .385  1.45  (0.88–2.37)  .135  Housing   Own a house  1.00  —  —  1.00  —  —  1.00  —  —  1.00  —  —   Rent a house  1.39  (1.18–1.64)  <.001  1.38  (0.82–2.32)  .212  1.84  (1.25–2.72)  .002  1.64  (0.93–2.90)  .080  Smoking status   Never smoker  1.00  —  —  1.00  —  —  1.00  —  —  1.00  —  —   Former smoker  1.55  (1.31–1.84)  <.001  1.21  (0.88–1.66)  .241  1.38  (0.99–1.91)  .053  1.50  (1.08–2.10)  .015    Control  Patients at high risk for SHS exposure  Patients with cancer  Patients with CVD  Patients with respiratory disease  OR  (95% CI)  p  OR  (95% CI)  p  OR  (95% CI)  p  OR  (95% CI)  p  Age  0.99  (0.98–1.00)  <.001  0.98  (0.97–1.00)  <.012  0.98  (0.96–0.99)  .002  0.98  (0.97–1.00)  .014  Gender   Female  1.00  —    1.00  —  —  1.00  —  —  1.00  —     Male  1.63  (1.44–1.84)  .001  1.41  (0.95–2.09)  .081  1.46  (1.06–1.99)  .017  1.47  (0.96–2.26)  .073  Education   College  1.00  —    1.00  —    1.00  —    1.00  —     Some college  1.56  (1.34–1.81)  <.001  1.03  (0.70–1.50)  .888  1.47  (1.00–2.17)  .046  1.40  (0.86–2.30)  .171   ≤High school  2.43  (2.06–2.86)  <.001  2.54  (1.70–3.81)  <.0001  2.33  (1.47–3.67)  <.001  4.08  (2.44–6.83)  <.001  Race/ethnicity   Non-Hispanic White  1.00  —  —  1.00  —  —  1.00  —  —  1.00  —  —   Mexican American  0.57  (0.45–0.73)  <.001  0.46  (0.23–0.90)  .022  0.50  (0.24–1.04)  .058  0.33  (0.18–0.58)  <.001   Other Hispanic  0.74  (0.57–0.95)  .018  0.47  (0.24–0.93)  .027  0.40  (0.21–0.74)  .003  0.44  (0.21–0.93)  .028   Non-Hispanic Black  2.21  (1.76–2.78)  <.001  2.42  (1.40–4.17)  .001  2.10  (1.38–3.21)  <.001  1.59  (1.01–2.50)  .041   Other race  1.79  (1.35–2.38)  <.001  2.19  (0.88–5.42)  .085  0.95  (0.47–1.91)  .874  1.37  (0.65–2.88)  .396  Marital status   Married/living with partner  1.00  —  —  1.00  —  —  1.00  —  —  1.00  —  —   Single/divorced/widow  1.37  (1.18–1.59)  <.001  1.11  (0.71–1.74)  .654  1.65  (1.12–2.43)  .010  1.54  (0.90–2.66)  .111   Never married  1.21  (1.01–1.45)  .036  0.91  (0.38–2.21)  .840  0.95  (0.54–1.68)  .861  0.92  (0.47–1.80)  .804  Family poverty index ratio   ≥Poverty level  1.00  —  —  1.00  —  —  1.00  —  —  1.00  —  —   <Poverty level  1.39  (1.14–1.68)  .001  1.99  (1.16–3.44)  .011  1.47  (0.88–2.45)  .130  2.57  (1.59–4.15)  <.001  Employment status   Employed  1.00  —  —  1.00  —  —  1.00  —  —  1.00  —  —   Unemployed  1.29  (1.11–1.50)  .001  1.35  (0.98–1.86)  .060  1.37  (0.83–2.84)  .242  1.35  (0.88–2.08)  .165  Health insurance   Yes  1.00  —  —  1.00  —  —  1.00  —  —  1.00  —  —   No  1.30  (1.02–1.65)  .033  1.36  (0.57–3.23)  .484  1.37  (0.66–2.84)  .385  1.45  (0.88–2.37)  .135  Housing   Own a house  1.00  —  —  1.00  —  —  1.00  —  —  1.00  —  —   Rent a house  1.39  (1.18–1.64)  <.001  1.38  (0.82–2.32)  .212  1.84  (1.25–2.72)  .002  1.64  (0.93–2.90)  .080  Smoking status   Never smoker  1.00  —  —  1.00  —  —  1.00  —  —  1.00  —  —   Former smoker  1.55  (1.31–1.84)  <.001  1.21  (0.88–1.66)  .241  1.38  (0.99–1.91)  .053  1.50  (1.08–2.10)  .015  Bolded values signify statistically significant findings at p < .05 level. CI, confidence interval; CVD, cardiovascular disease; OR, odds ratio; SHS, secondhand smoke. aNonsmoking adults who had a serum cotinine level of <10 ng/mL (the threshold for not being active smoker). bBased on serum cotinine level of 0.015–10 ng/mL. cPatients with cancer: Ever been told by a doctor or other health professional that they had cancer or a malignancy of any kind. dPatients with CVD: Ever been told by a doctor or other health professional that they had congestive heart failure, coronary heart disease, angina, heart attack, or stroke. ePatient with respiratory disease: Ever been told by a doctor or other health professional that they had asthma, chronic bronchitis, or emphysema. fNonsmoking adults without cancer, CVD, or respiratory disease. View Large Table 1. Multivariable Logistic Regression Analysis of Exposure to Secondhand Smoke Among Nonsmoking Adulta Who Are Exposedb to Secondhand Smoke and Have Cancerc, CVDd, or Respiratory Diseasee Compared With Controlf (Pooled Data From the 2001–2012 National Health and Nutrition Examination Survey)   Control  Patients at high risk for SHS exposure  Patients with cancer  Patients with CVD  Patients with respiratory disease  OR  (95% CI)  p  OR  (95% CI)  p  OR  (95% CI)  p  OR  (95% CI)  p  Age  0.99  (0.98–1.00)  <.001  0.98  (0.97–1.00)  <.012  0.98  (0.96–0.99)  .002  0.98  (0.97–1.00)  .014  Gender   Female  1.00  —    1.00  —  —  1.00  —  —  1.00  —     Male  1.63  (1.44–1.84)  .001  1.41  (0.95–2.09)  .081  1.46  (1.06–1.99)  .017  1.47  (0.96–2.26)  .073  Education   College  1.00  —    1.00  —    1.00  —    1.00  —     Some college  1.56  (1.34–1.81)  <.001  1.03  (0.70–1.50)  .888  1.47  (1.00–2.17)  .046  1.40  (0.86–2.30)  .171   ≤High school  2.43  (2.06–2.86)  <.001  2.54  (1.70–3.81)  <.0001  2.33  (1.47–3.67)  <.001  4.08  (2.44–6.83)  <.001  Race/ethnicity   Non-Hispanic White  1.00  —  —  1.00  —  —  1.00  —  —  1.00  —  —   Mexican American  0.57  (0.45–0.73)  <.001  0.46  (0.23–0.90)  .022  0.50  (0.24–1.04)  .058  0.33  (0.18–0.58)  <.001   Other Hispanic  0.74  (0.57–0.95)  .018  0.47  (0.24–0.93)  .027  0.40  (0.21–0.74)  .003  0.44  (0.21–0.93)  .028   Non-Hispanic Black  2.21  (1.76–2.78)  <.001  2.42  (1.40–4.17)  .001  2.10  (1.38–3.21)  <.001  1.59  (1.01–2.50)  .041   Other race  1.79  (1.35–2.38)  <.001  2.19  (0.88–5.42)  .085  0.95  (0.47–1.91)  .874  1.37  (0.65–2.88)  .396  Marital status   Married/living with partner  1.00  —  —  1.00  —  —  1.00  —  —  1.00  —  —   Single/divorced/widow  1.37  (1.18–1.59)  <.001  1.11  (0.71–1.74)  .654  1.65  (1.12–2.43)  .010  1.54  (0.90–2.66)  .111   Never married  1.21  (1.01–1.45)  .036  0.91  (0.38–2.21)  .840  0.95  (0.54–1.68)  .861  0.92  (0.47–1.80)  .804  Family poverty index ratio   ≥Poverty level  1.00  —  —  1.00  —  —  1.00  —  —  1.00  —  —   <Poverty level  1.39  (1.14–1.68)  .001  1.99  (1.16–3.44)  .011  1.47  (0.88–2.45)  .130  2.57  (1.59–4.15)  <.001  Employment status   Employed  1.00  —  —  1.00  —  —  1.00  —  —  1.00  —  —   Unemployed  1.29  (1.11–1.50)  .001  1.35  (0.98–1.86)  .060  1.37  (0.83–2.84)  .242  1.35  (0.88–2.08)  .165  Health insurance   Yes  1.00  —  —  1.00  —  —  1.00  —  —  1.00  —  —   No  1.30  (1.02–1.65)  .033  1.36  (0.57–3.23)  .484  1.37  (0.66–2.84)  .385  1.45  (0.88–2.37)  .135  Housing   Own a house  1.00  —  —  1.00  —  —  1.00  —  —  1.00  —  —   Rent a house  1.39  (1.18–1.64)  <.001  1.38  (0.82–2.32)  .212  1.84  (1.25–2.72)  .002  1.64  (0.93–2.90)  .080  Smoking status   Never smoker  1.00  —  —  1.00  —  —  1.00  —  —  1.00  —  —   Former smoker  1.55  (1.31–1.84)  <.001  1.21  (0.88–1.66)  .241  1.38  (0.99–1.91)  .053  1.50  (1.08–2.10)  .015    Control  Patients at high risk for SHS exposure  Patients with cancer  Patients with CVD  Patients with respiratory disease  OR  (95% CI)  p  OR  (95% CI)  p  OR  (95% CI)  p  OR  (95% CI)  p  Age  0.99  (0.98–1.00)  <.001  0.98  (0.97–1.00)  <.012  0.98  (0.96–0.99)  .002  0.98  (0.97–1.00)  .014  Gender   Female  1.00  —    1.00  —  —  1.00  —  —  1.00  —     Male  1.63  (1.44–1.84)  .001  1.41  (0.95–2.09)  .081  1.46  (1.06–1.99)  .017  1.47  (0.96–2.26)  .073  Education   College  1.00  —    1.00  —    1.00  —    1.00  —     Some college  1.56  (1.34–1.81)  <.001  1.03  (0.70–1.50)  .888  1.47  (1.00–2.17)  .046  1.40  (0.86–2.30)  .171   ≤High school  2.43  (2.06–2.86)  <.001  2.54  (1.70–3.81)  <.0001  2.33  (1.47–3.67)  <.001  4.08  (2.44–6.83)  <.001  Race/ethnicity   Non-Hispanic White  1.00  —  —  1.00  —  —  1.00  —  —  1.00  —  —   Mexican American  0.57  (0.45–0.73)  <.001  0.46  (0.23–0.90)  .022  0.50  (0.24–1.04)  .058  0.33  (0.18–0.58)  <.001   Other Hispanic  0.74  (0.57–0.95)  .018  0.47  (0.24–0.93)  .027  0.40  (0.21–0.74)  .003  0.44  (0.21–0.93)  .028   Non-Hispanic Black  2.21  (1.76–2.78)  <.001  2.42  (1.40–4.17)  .001  2.10  (1.38–3.21)  <.001  1.59  (1.01–2.50)  .041   Other race  1.79  (1.35–2.38)  <.001  2.19  (0.88–5.42)  .085  0.95  (0.47–1.91)  .874  1.37  (0.65–2.88)  .396  Marital status   Married/living with partner  1.00  —  —  1.00  —  —  1.00  —  —  1.00  —  —   Single/divorced/widow  1.37  (1.18–1.59)  <.001  1.11  (0.71–1.74)  .654  1.65  (1.12–2.43)  .010  1.54  (0.90–2.66)  .111   Never married  1.21  (1.01–1.45)  .036  0.91  (0.38–2.21)  .840  0.95  (0.54–1.68)  .861  0.92  (0.47–1.80)  .804  Family poverty index ratio   ≥Poverty level  1.00  —  —  1.00  —  —  1.00  —  —  1.00  —  —   <Poverty level  1.39  (1.14–1.68)  .001  1.99  (1.16–3.44)  .011  1.47  (0.88–2.45)  .130  2.57  (1.59–4.15)  <.001  Employment status   Employed  1.00  —  —  1.00  —  —  1.00  —  —  1.00  —  —   Unemployed  1.29  (1.11–1.50)  .001  1.35  (0.98–1.86)  .060  1.37  (0.83–2.84)  .242  1.35  (0.88–2.08)  .165  Health insurance   Yes  1.00  —  —  1.00  —  —  1.00  —  —  1.00  —  —   No  1.30  (1.02–1.65)  .033  1.36  (0.57–3.23)  .484  1.37  (0.66–2.84)  .385  1.45  (0.88–2.37)  .135  Housing   Own a house  1.00  —  —  1.00  —  —  1.00  —  —  1.00  —  —   Rent a house  1.39  (1.18–1.64)  <.001  1.38  (0.82–2.32)  .212  1.84  (1.25–2.72)  .002  1.64  (0.93–2.90)  .080  Smoking status   Never smoker  1.00  —  —  1.00  —  —  1.00  —  —  1.00  —  —   Former smoker  1.55  (1.31–1.84)  <.001  1.21  (0.88–1.66)  .241  1.38  (0.99–1.91)  .053  1.50  (1.08–2.10)  .015  Bolded values signify statistically significant findings at p < .05 level. CI, confidence interval; CVD, cardiovascular disease; OR, odds ratio; SHS, secondhand smoke. aNonsmoking adults who had a serum cotinine level of <10 ng/mL (the threshold for not being active smoker). bBased on serum cotinine level of 0.015–10 ng/mL. cPatients with cancer: Ever been told by a doctor or other health professional that they had cancer or a malignancy of any kind. dPatients with CVD: Ever been told by a doctor or other health professional that they had congestive heart failure, coronary heart disease, angina, heart attack, or stroke. ePatient with respiratory disease: Ever been told by a doctor or other health professional that they had asthma, chronic bronchitis, or emphysema. fNonsmoking adults without cancer, CVD, or respiratory disease. View Large Discussion This is the first study to describe the prevalence, time trends, and correlates of SHS exposure verified by serum cotinine analysis among a nationally representative sample of nonsmoking patients with cancer, CVD, or respiratory disease in the United States compared with individuals without these diseases (control group). Consistent with prior studies, our findings confirm that SHS exposure among these patients is very common and its decline is comparable to the general population,13–15 with the highest prevalence and least decline among patients with respiratory diseases. Finally, similar to the control group, disparities in exposure persist among these patients with the youngest, non-Hispanic Black, and less educated being among the most exposed. Strengthening smoke-free policies in workplaces, public place, and multiunit housing is critical. SHS exposure among these patients seems to be overlooked in clinical settings, particularly among patients with respiratory disease. Efforts are needed to address SHS exposure more effectively in clinical settings to increase patients’ awareness about the risk of exposure to SHS and help them reducing their exposure. Our study is the first to examine SHS exposure prevalence time trends in patients with cancer, CVD, and respiratory disease in the United States. Our findings show that over 12 years, the decline in SHS exposure was the most in CVD patients, and the least in patients with respiratory disease, and the difference in the decline between the control group and any of the disease groups was not significant. Of note, the decline in our control group was consistent and comparable with prior studies based on NHANES data.12 However, it is important to mention that SHS exposure prevalence in these studies were lower than our study (eg, 25.3% vs. 56.6% in 2012) because they used the old cutpoint of detection for serum cotinine less than 0.05 ng/mL, while we used the more sensitive new cut point of 0.015 ng/mL that has been the standard cut point in NHANES data since 2001 because of improvements in the method. Therefore, despite the decline in SHS exposure, a noteworthy proportion of our high-risk groups are still exposed to SHS, making the reduction in SHS exposure an important public health problem in the United States that requires more attention. In the United States, only few studies to date have evaluated exposure to SHS among these patient groups and tried to explore patients’ beliefs and clinicians’ action about SHS exposure. In a study investigating SHS exposure among hospitalized nonsmokers with CVD found that although 40.3% of these patients had detectable levels of a biomarker of SHS exposure, they were rarely screened for SHS exposure (17.3%) or advised to avoid it (1.4%).15 We found only two studies developed and tested a clinical-based interventions to eliminate SHS exposure among patients. Conducted in 2010, the first study developed and tested the effectiveness of a system-level nurse-delivered intervention implemented in two inpatient cardiac units in Boston, MA.16 The intervention was a system-level change in nurses’ workflow for admitting patients that added to the admission form a question assessing patients’ SHS exposure “Does anyone ever smoke in your home or car?”, a statement of advice to be read to all patients “In order to keep your heart healthy, you need to keep your home and car smoke free,” and a prompt reminding nurses to distribute a pamphlet about SHS exposure “Give the patient the smoke-free home pamphlet.” The intervention was evaluated among 352 nonsmokers hospitalized with coronary heart disease and proved to be effective in changing awareness and knowledge. Postintervention patients were more likely to recall being asked if a household member smokes, advised to keep their home and car smoke-free, and aware that SHS exposure is harmful. In the second study, investigators demonstrated the feasibility of implementing the same intervention in a general hospital.17 Similar attempts among cancer and respiratory patients do not yet exist. This study is limited by the cross-sectional design of NHANES, which prevents us from making causal inferences. Second, the cut points of serum cotinine can biologically vary by race/ethnicity and age.18,19 However, using a highly sensitive cut point of cotinine level (0.015 ng/mL) to determine exposure increases our ability to biologically detect SHS exposure.18 Despite these limitations, this report presents unique, nationally representative findings about a serious public health problem in the United States. In conclusion, our results indicate that modest progress has been made in reducing SHS exposure among patients at high risk for SHS exposure in the United States. Continued efforts to strengthen smoke-free policies in all settings are needed. Health care systems are missing an important opportunity to identify and intervene in this major modifiable risk factor, which could be lifesaving. The present study emphasizes the need to address this problem more effectively in health care settings and investigate specific interventions directed at the reduction in SHS exposure among these patients. Funding Funding for this study was provided in part by the Bankhead Coley Cancer Research grant 1BG06-341963 (P.I., DJL) and Flight Attendant Medical Research Institute (FAMRI) Clinical Innovator Award (#103006_CIA; P.I., TK-S). Declaration of Interests The coauthors and I wish to express that we have no financial or other relationships that might lead to a conflict of interest. In addition, we all have participated in the conception of this report and have assisted in revising the manuscript for important intellectual content; last, we have provided final approval of the enclosed report. Acknowledgments TA and KA were responsible for the study concept and design. KA conducted the statistical analyses. TA wrote the first draft of the manuscript, and all authors participated in critically revising and editing the manuscript. All authors contributed to and had approved the final manuscript. References 1. USDHHS. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General . Atlanta, GA: USDHHS, CDC, COCHP, NCCDPHP, OSH; 2006: 709. 2. Zhou W, Heist RS, Liu G, et al.   Second hand smoke exposure and survival in early-stage non-small-cell lung cancer patients. Clin Cancer Res . 2006; 12( 23): 7187– 7193. Google Scholar CrossRef Search ADS PubMed  3. Yeh ET, Bickford CL. Cardiovascular complications of cancer therapy: incidence, pathogenesis, diagnosis, and management. J Am Coll Cardiol . 2009; 53( 24): 2231– 2247. Google Scholar CrossRef Search ADS PubMed  4. 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This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

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Nicotine and Tobacco ResearchOxford University Press

Published: Mar 23, 2018

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