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8.A. - Page 34 support to this exposure -reduction strategy. Smoke-free policies should recognize that tobacco smoke drifts and can be measured in high quanti- ties more than 20 feet from an outdoor source.36 Because restriction inside apartments may encourage increased smoking in common areas where ex- posure to nonsmokers still may occur, these policies should include smoking restrictions for balconies, common porch areas, and entrances. Our overall prevalence of children ex- posed to tobacco smoke is signifi- cantly higher than that reported in the 2006 Surgeon General's report.6 This difference is most likely because the NHANES now uses high -sensitivity coti- nine testing that allows the detection of low levels of smoke exposure. Iden- tifying those at risk for these low levels of exposure is important because there is increasing evidence that even small or brief exposure to tobacco smoke can cause physiologically sig- nificant cardiovascular effects.37 Low- level exposure to tobacco smoke also has been associated with lower scores on cognitive testing.$ Although there was a significant asso- ciation between living in an apartment and cotinine levels for white and black children, this was not the case for those of Hispanic ethnicity or other races. Overall, Hispanic and Asian adults have much lower smoking rates (13.3% and 9.6%, respectively) than black (19.8%) or white (21.4%) adults. This difference particularly is striking for women (8.3% of Hispanic and 4.0% of Asian women smoke compared with 15.8% of black women and 19.8% of white women).37 Because Hispanic and Asian immigrants are more likelyto be found in high-density ethnic enclaves where multiunit housing is common,38 it is possible that the lower smoking prevalence among some ethnic groups reduces the overall tobacco -smoke burden in some multiunit housing. There are other potential sources of exposure that need to be considered. Potential sources may include daycare centers or child-care arrangements39 as well as smoke residue from a par- ent or caregiver who smokes outside. Other studies have found significantly increased house dust and air nicotine levels in households with a mother who smokes outside, with correspond- ing increases in children's urine cotin- ine level.15 There also is an increase in air and surface nicotine found in used cars previously owned by smokers.ao This is an important issue for families who may believe that they are protect- ing their children by smoking outside. However, because smoking prevalence is much lower than exposure preva- lence,37 this does not explain all of the excess exposure. There are limitations to these data. First, we only were able to examine the association between apartment living and tobacco -smoke exposure; there are other unmeasured potential con- founders. Population density and cur- rent smoke-free housing legislation are 2 factors that likely play a role; these will need to be examined in fu- ture research. In addition, the NHANES data set has no information about home smoking bans or outside smok- ing behavior, so we cannot know how many of these children have parents who smoke outside or if they are ex- posed at daycare centers or relatives' homes. We hope that future research will be ableto separate outthe individ- ual contributions of apartment smoke drift, outside -smoker "off -gassing" and thirdhand smoke, occasional in- side smoking by visitors, or exposures outside of the home. Finally, people who smoke may inaccu- rately report whether they smoke anywhere inside the home. If under- reporting rates varied between those in apartments versus single-family homes, our results may be biased. As- suming no differential in inaccurate reporting, children in apartments also might be expected to have higher coti- nine levels because of the smaller square footage in apartments versus single-family homes. In general, how- ever, people who smoke have demon- strated low rates of underreporting smoking behaviors in noninterven- tion trials.^' Finally, a growing number of buildings are smoke-free already,37leading to an underestima- tion of the exposure rate in multiunit dwellings where smoking still is allowed. CONCLUSIONS Most children in the US continue to be exposed to tobacco smoke, even with the growing knowledge of its damag- ing effects at low levels of exposure. It is vital to understand the contribution of all potential sources of exposure for children: parents smoking out- side, daycare, visiting homes where smoking is allowed, and from con- nected dwellings. However, signifi- cant tobacco -smoke contamination in the air of nonsmoking units of multi- unit housing already has been shown. This study is the first to document through human biological sampling that disseminated tobacco smoke from multiunit apartments may con- tribute to the actual exposure of chil- dren. In addition, there are likely to be many adult nonsmokers who also are exposed to tobacco smoke by this mechanism. Biochemical data demon- strating the increased risk of involun- tary tobacco -smoke exposure posed by living in apartments may change public opinion and policies about smoke-free multiunit housing for those who live in low-income hous- ing, and for those who live in apart- ments owned by private companies. These results provide direct evi- dence for a background level of tobacco -smoke contamination in multiunit housing at levels associ- 90 WILSON et al Downloaded from www.pediatrics.org. Provided by San Mateo Medical Center on December 13, 2010