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8.A. - Page 30
<br />Tobacco -smoke exposure causes ill-
<br />ness in children, including asthma','
<br />and respiratory infections,' and has
<br />been associated with sudden infant
<br />death syndrome,' metabolic syn-
<br />drome,' and otitis media.' There is no
<br />safe level of exposure to tobacco
<br />smokes Very low levels of tobacco -
<br />smoke exposure have been associated
<br />with attenuated endothelial function in
<br />children,' as well as decreased scores
<br />on reading, math, and block -design
<br />tests of cognitive function.' Morbidity
<br />has been documented in those with the
<br />lowest levels of cotinine (0.015-0.5 ng/
<br />mL), and these children have greater
<br />rates of conduct disorder.' Even brief
<br />exposure to ambient tobacco smoke
<br />can decrease lung function and cause
<br />persistent elevations in inflammatory
<br />cytokines.10
<br />Parental smoking is the most common
<br />source of secondhand tobacco -smoke
<br />exposure for children. In 1 study,' 25%
<br />of children aged 3 to 11 years report-
<br />edly lived with at least 1 smoker. How-
<br />ever, 60% of the children in the study
<br />had detectable levels of cotinine,' a
<br />metabolite specific to tobacco smoke.
<br />Other known exposures do not explain
<br />all of the 54% of children with elevated
<br />cotinine levels who had no identified
<br />smoker in the home."" These chil-
<br />dren, therefore, must have been ex-
<br />posed to other sources of tobacco
<br />smoke that are not being captured by
<br />parent report.
<br />Tobacco smoke can migrate through
<br />walls, ductwork, windows, and ventila-
<br />tion systems of multiunit dwellings
<br />and potentially affect residents in
<br />other units far removed from the
<br />smoking area.1113In additiontothe dis-
<br />semination of this secondhand smoke
<br />into other apartments, tobacco toxins
<br />may persist on and be absorbed from
<br />surfaces in the indoor environment
<br />well beyond the period of active smok-
<br />ing.14-16 This "thirdhand smoke"17 may
<br />re -emit deposited volatile compounds
<br />and particulate matter on indoor sur-
<br />faces, and particulate matter in dust
<br />may be resuspended into the air as re-
<br />spirable suspended particulate mat-
<br />ter.la.l',ls In addition to inhalation,
<br />there are other potential exposure
<br />routes, such as ingestion, that are par-
<br />ticularly likely in children .15
<br />Recent public health efforts to reduce
<br />tobacco smoke exposure have concen-
<br />trated on banning smoking in public
<br />places outside of the home, including
<br />workplaces, restaurants, and bars,
<br />leading to improved air quality in those
<br />locations.20 However, in New York City,
<br />where the prevalence of cigarette
<br />smoking is lower than the national av-
<br />erage and there are strict smoking
<br />bans in bars and restaurants, a recent
<br />study" found that the prevalence of el-
<br />evated cotinine levels among non-
<br />smoking adults was higher than the
<br />national average. The authors specu-
<br />lated that contamination of multiunit
<br />buildings with tobacco smoke from
<br />other units may contribute to these
<br />surprisingly high cotinine levels, al-
<br />though no direct measurement of nic-
<br />otine in the air was performed. Some
<br />municipalities have proposed legisla-
<br />tion to reduce or ban smoking in apart-
<br />ment buildings,22,23 and some public -
<br />housing authorities have implemented
<br />smoke-free policies." In 2009, the De-
<br />partment of Housing and Urban Devel-
<br />opment encouraged public -housing
<br />authorities to ban smoking in low-
<br />income multiunit housing.25 There also
<br />have been reports of privately owned
<br />housing units that have banned smok-
<br />ing because of the potential health
<br />risks, increased costs associated with
<br />removing tobacco residue from apart-
<br />ments after smoking tenants leave,
<br />and the need to relocate tenants dis-
<br />turbed by neighbors who smoke." A
<br />recent study" of low-income apart-
<br />ments in Boston found that 94% had
<br />detectable air nicotine levels, includ-
<br />ing 89% of apartments inhabited by
<br />nonsmokers.
<br />There still is a lack of scientific evi-
<br />dence about whether smoking in mul-
<br />tiunit housing accounts for the pres-
<br />ence of tobacco -smoke biomarkers in
<br />children who live in a home with no
<br />adult smokers. In the current study, we
<br />used data from the 2001-2006 Na-
<br />tional Health and Nutrition Examina-
<br />tion Survey (NHANES) to examine the
<br />association between types of housing
<br />and cotinine levels in children. We hy-
<br />pothesized that children who live in
<br />apartments have a higher cotinine
<br />level than children who live in de-
<br />tached homes and that this relation-
<br />ship persists when controlling for pov-
<br />erty and race/ethnicity.
<br />METHODS
<br />The NHANES
<br />The NHANES used a multistage sam-
<br />pling design that included a question-
<br />naire (parent and teen reports), phys-
<br />ical examination, and blood and urine
<br />samples. Survey components were ad-
<br />ministered to a proxy respondent for
<br />children up through 15 years of age,
<br />whereas children aged 16 to 18 years
<br />completed the survey responses them-
<br />selves unless they were cognitively un-
<br />able. Demographic variables included
<br />age, gender, and self-report of race
<br />and ethnicity. In addition, the federal
<br />poverty -level ratio was calculated. A
<br />federal poverty -level ratio below 1
<br />means the family lives below the pov-
<br />erty level, whereas a ratio above 1
<br />means they live above the poverty
<br />level.
<br />Housing Type
<br />Interviewers assessed housing type
<br />and asked respondents to verify their
<br />impressions. The response categories
<br />included detached house ("a one -
<br />family house detached from any other
<br />house"), apartment, attached house
<br />("a one -family house attached to one
<br />86 WILSON et al
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