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Intervention: Tobacco Control

Tobacco Smoke Exposure and Health-Care Utilization Among Children in the United States

Ashley L. Merianos, PhD, CHES 1 , Cathy Odar Stough, PhD

2 ,

Laura A. Nabors, PhD, ABPP 1 , and E. Melinda Mahabee-Gittens, MD, MS

3

Abstract

Purpose: The purpose of this study was to assess patterns of health-care utilization among children who potentially had tobacco smoke exposure (TSE) compared to those who were not exposed.

Design: A secondary data analysis of the 2011 to 2012 National Survey on Children’s Health was performed.

Setting: Households nationwide were selected.

Participants: A total of 95 677 children aged 0 to 17 years.

Measures: Sociodemographic characteristics, TSE status, and health-care visits were measured.

Analysis: Multivariable logistic regression models were performed.

Results: A total of 24.1% of children lived with smokers. Approximately 5% had home TSE. Participants who lived with a smoker were significantly more likely to have had a medical care visit (odds ratio [OR] ¼ 1.22, confidence interval [CI] ¼ 1.21-1.22) and were more likely to seek sick care or health advice at an emergency department (OR ¼ 1.23, CI ¼ 1.23-1.24) but were less likely to have had a dental care visit (OR ¼ 0.82, CI ¼ 0.82-0.83) than those who did not live with a smoker. Similar findings were found among participants who had home TSE.

Conclusion: TSE is a risk factor for increased use of pediatric medical care. Based on the high number of children who potentially had TSE and received sick care or health advice at an emergency emergency department, this setting may be a venue to deliver health messages to caregivers.

Keywords secondhand smoke, tobacco use, health-care utilization, pediatrics

Purpose

Tobacco smoke exposure (TSE) has been consistently associ-

ated with an increased prevalence of childhood morbidity

including increased bronchiolitis, asthma exacerbations,

respiratory infections, and sudden infant death syndrome. 1

Yet, in 2011 to 2012, 24.7 million US children were exposed

to tobacco smoke. 2

TSE-related illnesses may contribute to

increased demand for health-care services and they represent

a great proportion of preventable childhood morbidity. 1

Thus,

the American Academy of Pediatrics 3

(AAP) identifies tobacco

use as a pediatric disease due to the harm to children caused by

use and TSE. Further, the AAP encourages implementing

initiatives during all health-care visits in order to decrease TSE

and related harms.

Research on the association between TSE and health-care

utilization has produced inconsistent findings, suggesting a

complex relationship. Studies have reported caregiver smoking

and TSE exposure are associated with an increased number of

physician visits for children with asthma, 4

respiratory symp-

toms, 5

emergency department visits for respiratory symptoms, 6

and hospital admissions. 7

In contrast, TSE has been associated

with a decreased number of preventive care visits, 8

health-care

visits for asthma, 9

and hospital admissions for asthma. 4

Fur-

ther, some research has not found differences between TSE and

number of primary care visits, emergency visits, or hospital

1 Health Promotion and Education Program, School of Human Services,

University of Cincinnati, Cincinnati, OH, USA 2 Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children’s

Hospital Medical Center, Cincinnati, OH, USA 3

Division of Emergency Medicine, Cincinnati Children’s Hospital Medical

Center, College of Medicine, University of Cincinnati, Cincinnati, OH, USA

Corresponding Author:

Ashley L. Merianos, PhD, CHES, School of Human Services, University of

Cincinnati, PO Box 210068, Cincinnati, OH 45221, USA.

Email: [email protected]

American Journal of Health Promotion 2018, Vol. 32(1) 123-130 ª The Author(s) 2017 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0890117116686885 journals.sagepub.com/home/ahp

admissions. 8

For these reasons, examining patterns of health-

care utilization in a national sample of children who live with

smokers and have home TSE is warranted.

The aim of the present study was to compare patterns of

health-care utilization among children who were potentially

exposed to tobacco smoke compared to those who were not

exposed using a nationally representative sample of children

aged 0 to 17 years. We hypothesized that children who live

with smokers or have home TSE use more health-care services

than children who do not live with smokers or do not have

home TSE.

Methods

Design

The data for this study are from the 2011 to 2012 National

Survey on Children’s Health (NSCH), and the present study’s

analyses were performed in 2015. This survey was conducted

by the US Centers for Disease and Control Prevention’s

National Center for Health Statistics, with funding provided

from the US Department of Health and Human Services’

Maternal and Child Health Bureau. 10

The purpose of the survey

was to provide national and state-specific prevalence estimates

for a range of children’s health and well-being indicators in

combination with information on the child’s family context and

neighborhood environment. 10

Sample

The 2011 to 2012 NSCH was a telephone survey conducted

between February 2011 and June 2012. It consisted of a total

sample of 95 677 children from birth through 17 years of age,

with approximately 1 850 interviews collected per state. A list-

assisted random digit dial sample of landline telephone num-

bers and an independent random digit dial sample of cell phone

numbers were called to find households with children 0 to

17 years from each of the 50 states including the District of

Columbia. The cell phone sample was new for survey admin-

istration, and landline and cell phones make up the complete

sample. Prior research indicates that answering machines and

caller ID have contributed to a decline in response rates of

conducting telephone surveys and that individuals are substi-

tuting landline telephones with cell phones. 11,12

Thus, individ-

uals have a greater frequency of answering their cell phones

compared to a landline phone; the inclusion of cell phones may

have increased NSCH response rates. If more than 1 age-

eligible child lived in the household, 1 child was randomly

selected to be included in the study sample. Interviews lasted

on average 33 to 34 minutes and were conducted in English,

Spanish, or 1 of 4 Asian languages. The respondent was iden-

tified by the interviewer as a parent or guardian with knowl-

edge of the child’s health status and health-care. The interview

completion rate among known households with children was

54.1% for the landline sample and 41.2% for the cell phone sample.

13 The research ethics review board of National Center

for Health Statistics approved data collection procedures. Ver-

bal informed consent for survey participation was obtained

after informing respondents of the voluntary and confidential

nature of the survey. Analyses were conducted for the total

95 677 children from birth to 17 years of age.

Measures

1. We investigated 5 health-care visit outcome variables

using a yes/no scale:

a. Medical care visit was derived from the question

‘‘During the past 12 months, did [sampling child]

see a doctor, nurse, or other health-care professional

for any kind of medical care including sick child

care, well-child checkups, physical examinations,

and hospitalizations?’’

b. Preventive medical care visit was derived from the

question ‘‘During the past 12 months, did [sampling

child] see a doctor, nurse, or other health-care pro-

vider for preventive medical care such as physical

examination or well-child checkup?’’

c. Specialty care visit was derived from the question

‘‘Specialists are doctors like surgeons, heart doc-

tors, allergy doctors, skin doctors, and others who

specialize in one area of health-care. During the

past 12 months, did [sampling child] see a specialist

(other than a mental health professional)?’’

d. Dental care visit was derived from the question

‘‘During the past 12 months, how many times did

[sampling child] see a dentist for any kind of dental

care, including checkups, dental cleaning, X-rays, or

filling cavities?’’

e. Preventive dental care visit was derived from the

question ‘‘During the past 12 months, how many

times did [sampling child] see a dentist for preven-

tive dental care, such as checkups and dental

cleanings?’’

2. Usual place for sick care or health advice for the sampling

child was investigated using the question ‘‘Is there a place

that [sampling child] usually goes when (he/she) is sick or

you need advice about (his/her) health?’’ If respondents

answered ‘‘yes,’’ they were asked the following question:

‘‘Is it a doctor’s office, emergency department, hospital

outpatient department, clinic, or some other place?’’

The 2 main TSE variables were household smokers and

home TSE. The presence of household smokers was assessed

with the question ‘‘Does anyone in your household use cigar-

ettes, cigars, or pipe tobacco?’’ Home TSE was assessed with

the question ‘‘Does anyone smoke inside the child’s home?’’

and was only asked of respondents who answered ‘‘yes’’ to the

question on household smokers. If caregivers answered ‘‘yes’’

to both questions, the child was considered positive for both

household smokers and home TSE.

124 American Journal of Health Promotion 32(1)

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Covariates considered were the sampling child’s gender,

age, and race/ethnicity (white, black, Hispanic, and multira-

cial), mothers’ education (less than a high school graduate,

high school graduate, and more than high school), household

composition (2-parent biological or step families, single

mother, and other family type), household poverty status mea-

sured as a ratio of family income to federal poverty level (FPL;

<100%, 100%-199%, 200%-399%, and >400%), and insurance type (public, private, and no insurance).

Analysis

NSCH data were collected through a complex sample design

involving unequal selection probabilities of children within

households and stratification of households within states. We

applied sampling weights to adjust for potential nonresponse

biases and account for noncoverage of nontelephone house-

holds. Resulting estimates are generalizable to all US nonin-

stitutionalized children aged 0 to 17 years, since the weighting

procedure includes a raking adjustment to parallel each US

state’s weighted survey responses to selected demographic

characteristics of the state’s noninstitutionalized population

17 years and younger. Bivariate associations between whether

there was a household smoker and sociodemographic charac-

teristics were tested with w2 analyses. Similar analyses were performed between home TSE status and sociodemographics.

Then, multivariable regression analyses were performed to

examine whether (1) living with a household smoker or (2)

having home TSE predicted health-care utilization. Specifi-

cally, a series of multivariable logistic regression models with

a step-wise selection procedure were performed to derive the

odds ratios (OR) and covariate-adjusted prevalence of exposure

for each type of health-care visit outcome (ie, any medical visit,

preventive medical care visit, specialty care visit, any dental

care visit, and preventive dental care visit) and usual place for

sick care or health advice (eg, doctor’s office, emergency

department). All data were conducted by using SPSS version

23.0.

Results

Child gender had near equal distribution: 51.2% were males and 48.8% were females. The majority of sampling children were white (52.5%) followed by Hispanic (23.0%), black (13.5%), and multiracial (10.3%). Two-thirds of the children lived in a biological, 2-parent home (65.6%), 19.0% lived with a single mother, 8.8% lived in a step family, 2-parent home, and 6.7% had other family household composition. Most moth- ers of sampling children completed more than high school

(63.8%), 21.9% were high school graduates, and 14.3% did not graduate from high school. Based on FPL, 22.4% had a family income less than 100% FPL, 21.5% were 100% to 199% FPL, 28.5% were 200% to 399% FPL, and 27.8% had a family income more than 400% FPL. More than half had private health insurance (57.4%), 37.1% had public health insurance (eg, Medicaid, Children’s Medicaid), and 5.6% were currently

uninsured. A total of 24.1% of the 95 677 children lived with smokers. Approximately 5% had home TSE.

In the past 12 months of survey completion, a total of 88.1% children had any medical care visit, 84.4% had a preventive medical care visit, 22.6% had a specialty care visit, 77.5% had any dental care visit, and 77.2% had a preventive dental care visit. Most sampling children (91.4%) had a usual place for sick care or health advice; 76.6% usually went to a doctor’s office for sick care or health advice, 2.4% usually went to a hospital emergency department, 2.4% usually went to a hospital out- patient department, 18.4% usually went to a clinic or health center, and 0.1% usually went to a retail store or minute clinic.

Sociodemographic characteristics in relation to house-

hold smokers and home TSE are described in Table 1.

Child’s gender, age, race/ethnicity, household composition,

mother’s education, household poverty status, and insur-

ance type significantly differed based on household smo-

kers and home TSE.

A series of multivariable logistic regression models, while

adjusting for covariates, indicated that children who lived with

a smoker were more likely to have had a preventive visit (odds

ratio [OR] ¼ 1.10, confidence interval [CI] ¼ 1.09-1.10), a specialty visit (OR ¼ 1.01, CI ¼ 1.00-1.01), or a medical care visit including sick care, checkups, or physical examinations

(OR ¼ 1.22, CI ¼ 1.21-1.22). Children who lived with a smo- ker were less likely to have had a dental care visit (OR ¼ 0.82, CI ¼ 0.82-0.83) or preventive dental care visit (OR ¼ 0.81, CI ¼ 0.80-0.81; Table 2). Overall, children who lived with a smo- ker were more likely to have a usual place for sick care or

health advice (OR ¼ 1.03, CI ¼ 1.03-1.03); specifically, chil- dren were significantly more likely to have usual care at the

following places: a doctor’s office (OR ¼ 1.05, CI ¼ 1.05-1.06), hospital emergency department (OR ¼ 1.23, CI ¼ 1.23-1.24), hospital outpatient department (OR ¼ 1.01, CI ¼ 1.00-1.01), or retail store or minute clinic (OR ¼ 1.53, CI ¼ 1.50-1.55). Children who lived with a smoker were less likely to report

a clinic or health center (OR ¼ 0.92, CI ¼ 0.92-0.92) as a usual place for sick care or health advice.

Multivariable logistic regression analyses indicated that

children who had home TSE were more likely to have had a

medical care visit (OR ¼ 1.35, CI ¼ 1.34-1.35) or a preventive care visit (OR ¼ 1.32, CI ¼ 1.31-1.32). Children who had home TSE were less likely to have had a specialty care visit

(OR ¼ 0.92, CI ¼ 0.91-0.92), a dental care visit (OR ¼ 0.77, CI ¼ 0.76-0.77), or a preventive dental care visit (OR ¼ 0.73, CI ¼ 0.73-0.74; Table 3). Overall, children who had home TSE were less likely to have a usual place for sick care or health

advice (OR ¼ 0.90, CI ¼ 0.90-0.91); children were signifi- cantly less likely to have usual care at a clinic or health center

(OR ¼ 0.85, CI ¼ 0.85-0.86). Children who had home TSE were more likely to have usual care at the following places: a

doctor’s office (OR ¼ 1.06, CI ¼ 1.05-1.06), a hospital emer- gency department (OR ¼ 1.40, CI ¼ 1.38-1.40), a hospital outpatient department (OR ¼ 1.19, CI ¼ 1.18-1.20), or a retail store or minute clinic (OR ¼ 1.30, CI ¼ 1.26-1.34) as usual places for sick care or health advice.

Merianos et al. 125

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Discussion

Among a nationally representative sample, approximately one-

quarter of children lived with a smoker corresponding to a

weighted total of 17.6 million children and approximately

5% had home TSE equivalent to 3.6 million children. Com- pared to the 2007 NSCH, self-reported rates of TSE have

decreased over the past several years from 19.1 million chil-

dren who lived with a smoker (26.2%) and 5.5 million children who had home TSE (7.6%).14 Although self-reported NSCH TSE rates have slightly decreased, recent research that assessed

TSE using serum cotinine, a metabolite of nicotine that is an

optimal assessment of TSE, 15

found that 15 million children

aged 3 to 11 years and 9.6 million children aged 12 to 19 years

were exposed to tobacco smoke. 2

These higher rates, compared

to the present study’s results, are not surprising since caregivers

typically do not report their child’s accurate level of TSE. 6,16,17

Thus, it is important to note that children who live with a

smoker, despite reporting no one smokes inside the home, are

still at risk of exposure.

We found a considerable difference between self-reported

rates of smokers in the home compared to home TSE. This

association suggests that home TSE rates may actually be

higher than the rates self-reported by caregivers, given that

the home is the most common source of TSE for children. 18

Additionally, prior evidence suggests that the majority of

nonsmokers who live with a smoker are exposed to TSE. 19

As smoke-free policies have increased in public places and

work places in recent years, private settings such as homes

and cars are becoming greater sources of exposure. 18

The

prevalence of home smoking bans has increased over the past

2 decades, but there has been a disproportionately slower

decline in home TSE since less than half of households with

a smoker have adopted voluntary smoke-free home rules. 20

Thus, efforts are still widely needed to promote voluntary

smoke-free policies in the home and to encourage smoking

cessation among caregivers.

As hypothesized and similar to previous research, 4,5

chil-

dren who lived with a smoker and who had home TSE were

more likely to have had any medical care visit including sick

Table 1. Sociodemographic Characteristics of Children 0 to 17 Years Old by Household Smokers and Home TSE in the United States, 2011 to 2012.

Sociodemographic Characteristics

Household Smokers Home TSE

Lives With Nonsmoker (n ¼ 72 617), n (%)a

Lives With Smoker (n ¼ 22 137), n (%)a P Value

No Home TSE (n ¼ 90 125), n (%)a

Home TSE (n ¼ 4623), n (%)a P Value

Child gender Female 35 262 (76.1) 10 651 (23.9) <.001 43 710 (95.2) 2199 (4.8) <.001 Male 32 276 (75.7) 11 463 (24.3) 46 314 (95.0) 2423 (5.0)

Child age 0-9 years old 38 316 (76.4) 11 557 (23.6) <.001 48 182 (96.7) 1687 (3.3) <.001 10-17 years old 34 301 (75.2) 10 580 (24.8) 41 943 (93.1) 2936 (6.9)

Child race/ethnicity White 47 101 (73.9) 14 217 (26.1) <.001 58 472 (94.8) 2843 (5.2) <.001 Black 6731 (75.0) 2132 (25.0) 8073 (91.0) 790 (9.0) Hispanic 10 033 (81.7) 2637 (18.3) 12 312 (98.1) 358 (1.9) Multiracial 7598 (73.5) 2840 (26.5) 9872 (94.9) 566 (5.1)

Household composition 2-parent biological 53 788 (80.3) 12 295 (19.7) <.001 64 155 (97.1) 1924 (2.9) <.001 2-parent stepfamily 3854 (59.1) 2696 (40.9) 5891 (90.4) 658 (9.6) Single mother 10 290 (71.0) 4800 (29.0) 13 759 (91.5) 1331 (8.5) Other family type 4296 (67.6) 2227 (32.4) 5841 (91.2) 681 (8.8)

Mother education Less than high school 4183 (70.5) 2505 (29.5) <.001 6019 (92.9) 669 (7.1) <.001 High school graduate 10 002 (64.2) 6046 (35.8) 14 599 (91.4) 1447 (8.6) More than high school 53 419 (82.0) 11 147 (18.0) 62 785 (97.3) 1781 (2.7)

Household poverty status <100% 8924 (66.3) 5832 (33.7) <.001 13 032 (90.4) 1721 (9.6) <.001 100%-199% 11 379 (68.6) 5 634 (31.4) 15 649 (92.9) 1364 (7.1) 200%-399% 22 400 (77.4) 6298 (22.6) 27 644 (96.8) 1053 (3.2) �400% 29 914 (87.8) 4373 (12.2) 33 800 (98.8) 485 (1.2)

Insurance type Public 16 832 (66.0) 10 246 (34.0) <.001 24 379 (91.5) 2695 (8.5) <.001 Private 52 344 (82.9) 10 208 (17.1) 61 043 (97.6) 1507 (2.4) No insurance 2642 (70.6) 1338 (29.4) 3636 (93.9) 344 (6.1)

Abbreviation: TSE, tobacco smoke exposure. a n refers to raw scores and percentages are weighted.

126 American Journal of Health Promotion 32(1)

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care, checkups, or physical examinations in the past year.

Greater use of any medical care may be related to the fact that

children with TSE are more likely to experience a variety of

health conditions and illnesses. 21,22

Further, it is particularly

concerning that children with TSE are less likely to have a

usual place of care due to recent efforts to increase the presence

of patient-centered medical homes. Lack of a usual place of

care also limits the opportunities for medical providers to mon-

itor changes in these children’s health over time. When chil-

dren with TSE do have a regular place of care, emergency

departments and retail store/minute clinics were the most likely

sources of care, suggesting these settings may be suitable

venues for providing interventions for these families.

Children who lived with a smoker and who had home TSE

were significantly more likely to seek sick care or health

advice at an emergency department. Research indicates that

there are high rates of biochemically validated TSE in chil-

dren who present to the pediatric emergency department. 6

Given the high acceptability of tobacco-related interventions

among caregivers who smoke in this setting, 23

the emergency

department may be an optimal venue for delivering interven-

tions to decrease child TSE and increase caregiver quit

attempts. 24,25

Contrary to our hypothesis, children who lived with a smo-

ker and who had home TSE were less likely to have had a

dental care visit including checkups, X-rays, or fillings in the

past year. This association is concerning, given children with

TSE are at greater risk of dental caries. 26

Further, smoking

cessation interventions at dental visits are not widespread. 27,28

Taken together, efforts are needed to increase dental visits

among children who have TSE and to increase smoking cessa-

tion counseling among smokers during dental visits.

Table 2. Adjusted Prevalence Health-Care Visits According to Household Smokers in Children 0 to 17 Years Old in the United States, 2011 to 2012.

Household Smokers

Health-Care Visits Multivariable Regression a

No, n (%)b Yes, n (%)b OR 95% CI

Any medical care visit Child lives with nonsmoker 7086 (11.6) 65 435 (88.4) Ref Ref Child lives with smoker 2655 (12.5) 19 438 (87.5) 1.22c 1.21-1.22

Preventive medical care visit Child lives with nonsmoker 10 339 (15.1) 61 772 (84.9) Ref Ref Child lives with smoker 3815 (16.9) 18 100 (83.1) 1.10c 1.09-1.10

Specialty care visit Child lives with nonsmoker 53 742 (76.8) 18 813 (23.2) Ref Ref Child lives with smoker 17 049 (79.2) 5059 (20.8) 1.01c 1.00-1.01

Any dental care visit Child lives with nonsmoker 12 061 (21.0) 56 482 (79.0) Ref Ref Child lives with smoker 5372 (27.1) 15 617 (72.9) 0.82c 0.82-0.83

Preventive dental care visit Child lives with nonsmoker 12 265 (21.3) 56 184 (78.7) Ref Ref Child lives with smoker 5490 (27.8) 15 447 (72.2) 0.81

c 0.80-0.81

Has usual place for sick care or health advice Child lives with nonsmoker 4019 (8.4) 68 473 (91.6) Ref Ref Child lives with smoker 1680 (9.1) 20 410 (90.9) 1.03c 1.03-1.03

Doctor’s office as usual place for sick care or health advice Child lives with nonsmoker 14 172 (22.8) 54 822 (77.2) Ref Ref Child lives with smoker 5396 (25.3) 15 461 (74.7) 1.05

c 1.05-1.06

Hospital emergency department as usual place for sick care or health advice Child lives with nonsmoker 68 130 (97.9) 864 (2.1) Ref Ref Child lives with smoker 20 315 (96.8) 542 (3.2) 1.23c 1.23-1.24

Hospital outpatient department as usual place for sick care or health advice Child lives with nonsmoker 67 507 (97.6) 1487 (2.4) Ref Ref Child lives with smoker 20 244 (97.4) 613 (2.6) 1.01

c 1.00-1.01

Clinic or health center as usual place for sick care or health advice Child lives with nonsmoker 57 231 (81.9) 11 763 (18.1) Ref Ref Child lives with smoker 16 640 (80.7) 4217 (19.3) 0.92c 0.92-0.92

Retail store/minute clinic as usual place for sick care or health advice Child lives with nonsmoker 68 936 (99.9) 58 (0.1) Ref Ref Child lives with smoker 20 833 (99.9) 24 (0.1) 1.53c 1.50-1.55

Abbreviations: CI, confidence interval; OR, odds ratio; Ref, referent. aStep-wise regression controlling for mother education, household composition, poverty level, insurance, child gender, child age, and child race/ethnicity. bn refers to raw scores and percentages are weighted. c P < .001.

Merianos et al. 127

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Limitations

There are several factors that may limit the generalizability of

the study results. For instance, data are based on self-report,

and as such social desirability may have influenced information

provided by caregivers who might have been very sensitive to

reporting if they smoked in the home. The NSCH may have

resulted in sampling bias that influenced parameter estimates

due to the data collection procedures. Although the NSCH may

not be truly representative of the US population due to the low

capture rate, the NSCH does provide information consistent

with the overall survey’s purpose to provide estimates of child

data for key health indicators and generate information about

children, their families, and neighborhoods. Further, the phras-

ing of the home TSE question may have also influenced social

desirability bias (eg, ‘‘inside the child’s home’’ vs ‘‘in your

home’’). Based on the self-report nature of the TSE questions,

underreporting or overreporting may have occurred. 29,30

Bio-

chemical validation of results would provide a more precise

measure of TSE. Due to self-report, caregivers may have not

known the differences between what type of place (eg, doctor’s

office vs clinic or health center) they go most often for their

child’s medical care. Data from behavioral observations,

reports from another family member, or biochemical validation

of the child’s TSE status would provide a way to verify infor-

mation provided by caregivers. The NCHS does not measure

the child’s smoking status, which may confound results in the

older age group. The NCHS is cross-sectional in nature. Evi-

dence on the impact of TSE over the course of children’s

development would provide more information on health-care

utilization. Finally, analyses were based on single items or

Table 3. Adjusted Prevalence of Health-Care Visits According to Home TSE Among Children 0 to 17 Years Old in the United States, 2011 to 2012.

Home TSE

Health-Care Visits Multivariable Regression a

No, n (%)b Yes, n (%)b OR 95% CI

Any medical care visit No home TSE 9071 (11.7) 80 391 (88.3) Ref Ref Home TSE 669 (13.3) 3937 (86.7) 1.35c 1.34-1.35

Preventive medical care visit No home TSE 13 211 (15.5) 76 241 (84.5) Ref Ref Home TSE 942 (17.1) 3626 (82.9) 1.32c 1.31-1.32

Specialty care visit No home TSE 67 162 (77.2) 22 883 (22.8) Ref Ref Home TSE 3626 (80.3) 986 (19.7) 0.92c 0.91-0.92

Any type of dental care visit No home TSE 16 188 (22.2) 68 810 (77.8) Ref Ref Home TSE 1244 (27.4) 3285 (72.6) 0.77c 0.76-0.77

Preventive dental care visit No home TSE 16 481 (22.6) 68 386 (77.4) Ref Ref Home TSE 1273 (28.5) 3241 (71.5) 0.73

c 0.73-0.74

Has usual place for sick care or health advice No home TSE 5240 (8.4) 84 718 (91.6) Ref Ref Home TSE 459 (12.1) 4159 (87.9) 0.90c 0.90-0.91

Doctor’s office as usual place for sick care or health advice No home TSE 18 311 (23.2) 67 235 (76.8) Ref Ref Home TSE 1255 (26.8) 3044 (73.2) 1.06

c 1.05-1.06

Hospital emergency department as usual place for sick care or health advice No home TSE 84 304 (97.7) 1242 (2.3) Ref Ref Home TSE 4135 (95.4) 164 (4.6) 1.40c 1.38-1.40

Hospital outpatient department as usual place for sick care or health advice No home TSE 83 578 (97.6) 1968 (2.4) Ref Ref Home TSE 4167 (96.8) 132 (3.2) 1.19

c 1.18-1.20

Clinic or health center as usual place for sick care or health advice No home TSE 70 521 (81.6) 15 025 (18.4) Ref Ref Home TSE 3346 (81.2) 953 (18.8) 0.85c 0.85-0.86

Retail store/minute clinic as usual place for sick care or health advice No home TSE 85 470 (99.9) 76 (0.1) Ref Ref Home TSE 4293 (99.9) 6 (0.1) 1.30c 1.26-1.34

Abbreviations: CI, confidence interval; OR, odds ratio; Ref, referent; TSE, tobacco smoke exposure. aStep-wise regression controlling for mother education, …