Original articlesAssessment of environmental tobacco smoke exposure in children with asthmatic symptoms by questionnaire and cotinine concentrations in plasma, saliva, and urine
Introduction
Increased prevalence of maternal smoking as well as levels of the nicotine metabolite cotinine in urine was found in consecutive new cases of severe childhood asthma, compared to referent children, indicating that ETS exposure is a risk factor [1]. However, the relationship between ETS exposure and asthma in different studies has not been consistent [2]. This could be due to different study designs. For example, we know little about the smoking behavior of parents of children with asthma after the onset of symptoms.
Further, the exposure assessment in most investigations are based on self-reports [3]; hence, they could be biased [4]. For example, there is a possibility of deceptive underreporting of exposure in children by smoking parents. Further, several factors are of importance for the exposure, such as the amount of tobacco smoked, room size, ventilation, and proximity to smokers. Also, exposure may occur outside the home, for example, in cars [5]. It may be difficult to estimate these factors in a questionnaire. Biomarkers of ETS exposure may be used for validation of ETS questionnaire.
We found that cotinine, determined in saliva [6] and in urine [7], were useful as biomarkers of ETS exposure. Plasma levels have also been used [8]. However, the relationship between concentrations of cotinine in plasma, saliva, and urine and ETS exposure has not been investigated.
Therefore, in the present study, the relationships between information on ETS exposure in a detailed ETS questionnaire, on the one hand, and cotinine concentrations in plasma, saliva, and urine on the other were investigated in children who suffered asthma and in referents.
Section snippets
Subjects
Out of a population sample of urban children (N = 2684) living in southern part of Sweden [9], who had answered a questionnaire on airways symptoms and exposures, all 137 children with asthmatic symptoms living in Malmö, Sweden were, during the winter (November–January), invited to a medical examination, including sampling of plasma, saliva, and urine. However, 52 children [mean age: 10.3 (8–13) years, 31 (60%) were boys] did not participate for different reasons, including acute illness. There
Cotinine and questionnaire data on ETS exposure
The median levels of cotinine in children were low (plasma 0.60 μg/l; saliva 0.30 μg/l; urine 0.53 μg/g crea) in homes who reported no indoor smoking, and increased considerably with smoking in the home by parents or others (Table 1). If both parents (with or without other smokers) reported that they were currently smoking in their home, the median cotinine concentrations in children were about 3, 9, and 17 times higher for plasma, saliva, and urine, respectively, compared to homes with no
Discussion
The most interesting findings of the present study were: a detailed questionnaire on ETS exposure only explained a limited fraction of the variance in the biomarkers of ETS exposure; maternal smoking was most important; plasma, saliva, and urinary cotinine concentrations in children were closely associated, but with a variation; and children with a history of asthmatic symptoms had lower current ETS exposure than referent children, in spite of the fact that the latter were few.
Selection biases
Acknowledgements
This study has been supported by grants from the Swedish Association against Asthma and Allergy, the National Swedish Environment Protection Agency, the Swedish Work Environment Fund, the Medical Faculty at Lund University and the European Commission (Biomed 1). Thanks to Ms. Inger Bensryd, RN, Anita Nilsson, RN, Ms. Kerstin Diab, RN, and Ms. Pia Aprea.
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