The Diverging Trend in Exposure to Environmental Tobacco Smoke Among US Children

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Journal of Racial and Ethnic Health Disparities





Environmental tobacco smoke exposure (ETSE) was race/ethnicity-specific, but how the race/ethnicity-specific ETSE has changed over time, diverging or converging, remains unclear. We examined ETSE trends by race/ethnicity in US children aged 3–11 years.


We analyzed the data of 9678 children who participated in the biennial National Health and Nutrition Examination Surveys, 1999–2018. ETSE was defined as serum cotinine ≥ 0.05 ng/ml, with ≥ 1 ng/ml as heavy exposure. For trend description, adjusted biennial prevalence ratios (abiPR: the ratio associated with a 2-year increase in time) were estimated by race/ethnicity. The prevalence ratios between races/ethnicities were used to quantify ethnoracial differences in different survey periods. Analyses were performed in 2021.


The overall ETSE prevalence was cut by almost half, from 61.59% (95% confidence interval = 56.55%, 66.62%) in the 1999–2004 survey to 37.61% (33.90%, 41.31%) in 2013–2018, exceeding the national 2020 health target (47.0%). However, the decrease occurred unequally between races/ethnicities. Heavy ETSE declined significantly in white [abiPR = 0.80 (0.74, 0.86)] and Hispanic children [0.83 (0.74, 0.93)], but insignificantly in black children [0.97 (0.92, 1.03)]. Consequently, the adjusted prevalence ratio between black children and white children increased from 0.82 (0.47, 1.44) in 1999–2004 to 2.73 (1.51, 4.92) in 2013–2018 for heavy ETSE. Hispanic children remained at the lowest risk throughout the study period.


Overall ETSE prevalence was cut by half between 1999 and 2018. However, due to uneven declines, the gaps between black children and others have expanded in heavy ETSE. Special vigilance is needed in preventive medicine practice with black children.


Georgia Southern University faculty member, Jian Zhang co-authored The Diverging Trend in Exposure to Environmental Tobacco Smoke Among US Children.


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