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(Chest. 2002;122:826-828.)
© 2002 American College of Chest Physicians

Environmental Tobacco Smoke Exposure During Travel Among Adults With Asthma*

Mark D. Eisner, MD, MPH, FCCP and Paul D. Blanc, MD, MSPH, FCCP

* From the Division of Occupational and Environmental Medicine, Department of Medicine, University of California, San Francisco, CA.

Correspondence to: Mark D. Eisner, MD, MPH, FCCP, Division of Occupational and Environmental Medicine, University of California, San Francisco, 350 Parnassus Ave, Suite 609, San Francisco, CA 94117; e-mail: eisner{at}itsa.ucsf.edu


   Abstract
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 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 References
 
Objectives: In California, state law now prohibits smoking in most public places. We examined the prevalence and short-term health impact of environmental tobacco smoke (ETS) exposure during travel among adults with asthma.

Design, setting, and participants: A cohort of 374 nonsmoking adults with asthma recruited from a random sample of allergy, pulmonary, and family practice physicians in northern California underwent structured telephone interviews.

Measurements and results: The prevalence of self-reported ETS exposure during travel in the past 12 months was substantial (30%; 95% confidence interval, 25 to 35%). Of the exposed subjects, approximately one third (34%) indicated no other regular source of ETS exposure. ETS-related cough, wheezing, or chest tightness during travel was the most common complaint (66%), followed by eye irritation (46%) and nose irritation (43%). After ETS exposure, many subjects indicated extra inhaled asthma medication use (55%). Subjects with no other regular ETS exposure reported a greater likelihood of eye irritation (58% vs 40%; p = 0.068) and nose irritation (58% vs 36%; p = 0.025) than persons with regular exposure. In contrast, there were no differences in respiratory symptoms, asthma medication use, or asthma exacerbation by regular ETS exposure status.

Conclusions: In adults with asthma, ETS exposure is common during travel. For many subjects, travel is their principal source of exposure.

Key Words: adverse effects • asthma • smoking • tobacco smoke pollution • travel


   Introduction
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 Abstract
 Introduction
Materials and Methods
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Environmental tobacco smoke (ETS) exposure has been linked with many adverse health consequences, ranging from asthma exacerbation to lung cancer.1 2 3 Epidemiologic studies have generally focused on home and workplace ETS exposure. In California, the primary locations of ETS exposure appear to be changing. Since 1995, state law has prohibited smoking in most workplaces.4 Beginning in 1998, smoke-free bars and taverns were legally mandated.5 As a consequence, most public places are now smoke-free throughout the state. Because public smoking essentially has been prohibited in California, we reasoned that travel would become a more significant source of ETS exposure. In an ongoing cohort study of adults with asthma, we evaluated the prevalence and short-term health impact of ETS exposure during vacation and business travel.


   Materials and Methods
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 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 References
 
We used data collected during an ongoing prospective, longitudinal cohort study of adults with asthma recruited from physician practices in Northern California. Details of recruitment have been reported previously.6 7 8 In brief, we recruited subjects from a random sample of certified American Board of Medical Specialty internal medicine and pulmonary specialists, internal medicine and allergy/immunology specialists, and family practice specialists. The present study eligibility is based on follow-up interviews conducted between July 1998 and December 1999, which included 401 subjects. In the present analysis, we excluded 27 current cigarette smokers, leaving 374 subjects. The study was approved by the University of California San Francisco Committee on Human Research.

Subjects underwent structured telephone interviews that included assessment of recent ETS exposure in various locations (during the 7 days before interview) and exposure during travel in the 12 months before interview. Specifically, subjects were asked, "In the past 12 months, have you taken a vacation or business trip where you were noticeably exposed to someone else’s tobacco smoke?" For subjects who indicated any travel exposure, we also ascertained sensory irritation and respiratory symptoms after ETS exposure. These included red eyes or eye irritation, runny nose or nose irritation, and coughing, wheezing, or chest tightness. The interview also assessed extra inhaled asthma medication use: "On this trip, did you use any extra asthma sprays after exposure to tobacco smoke?" The interview also assessed whether the subject had a symptomatic asthma exacerbation after ETS exposure during the 12 months before interview.

The data were analyzed using statistical software (SAS version 6.12; SAS Institute; Cary, NC). We report the prevalence of self-reported ETS exposure during travel and ETS-attributed sensory irritation symptoms, respiratory symptoms, extra inhaled medication use, and asthma exacerbation. For proportions, we calculated the exact binomial 95% confidence interval. Using the {chi}2 test, we also examined whether the self-reported short-term health impact of ETS exposure was greater among persons without recent regular ETS exposure, defined as living with a smoker or exposure during the 7 days before interview in various environments (home, another person’s home, vehicle, workplace, bar, or nightclub).


   Results
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 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 References
 
The average age (mean ± SD) of the 374 nonsmoking adults with asthma was 44 ± 7.7 years. Subjects included 264 women (71%) and 105 people of nonwhite race/ethnicity (28%). Fewer than one half of subjects indicated past cigarette smoking (n = 120; 32%).

The prevalence of self-reported ETS exposure during travel in the 12 months before interview was substantial (n = 111; 30%; 95% confidence interval, 25 to 35%). Of the people reporting travel-related ETS exposure, 38 subjects (34%) did not live with a smoker or indicate other sources of ongoing ETS exposure. For these subjects, travel was apparently their principal source of exposure.

Many subjects reported ETS-attributed sensory irritation or respiratory symptoms during travel (Table 1 ). The most common complaint was ETS-related cough, wheezing, or chest tightness (66%), followed by eye irritation (46%) and nose irritation (43%). After ETS exposure, many subjects indicated extra inhaled asthma medication use (55%) or asthma exacerbation (54%). Compared with people with a regular source of ETS exposure, those without regular exposure indicated a greater likelihood of eye or nose irritation after ETS exposure (Table 1) . In contrast, the prevalence of exposure-related cough, extra asthma medication use, and asthma exacerbation was similar in both groups.


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  		Table 1. Self-Reported Sensory Irritation and Respiratory Symptoms Following ETS Exposure During Travel in the Past 12 Months*

 
During the past 5 years, most people with asthma reported that their overall ETS exposure, taking all situations and locations into account, had decreased (n = 250 of the entire cohort of 374 subjects; 67%). A substantial proportion of subjects indicated that their exposure had decreased a great deal (n = 162; 43%). Fewer subjects reported no change in exposure (n = 94; 25%) or increased exposure (n = 30; 8%).


   Discussion
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 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
References
 
As public smoking becomes more restricted in California, ETS exposure during travel may be a relatively more important source of exposure. Nearly one third of subject reported ETS exposure during travel in the past year. Of these subjects, a substantial proportion indicated no other regular source of ETS exposure (34%).

The health impact of intermittent ETS exposure during travel has not been examined previously. In people with asthma, who may comprise a vulnerable group, travel-related ETS exposure was associated with a high prevalence of sensory irritation symptoms and respiratory symptoms. More than one half of these adults with asthma indicated that travel-related exposure exacerbated their asthma or necessitated additional inhaled medication use.

Compared with people with regular ETS exposure, travel-related ETS exposure was more strongly associated with sensory irritation symptoms among those without regular exposure. Our findings may indicate that subjects who are sensitive to ETS selectively avoid regular exposure. During travel, when exposure may be less avoidable, these subjects experience a greater likelihood of sensory irritation symptoms than subjects who are less sensitive. Previous research confirms that ETS sensitive subjects experience a greater physiologic effect after experimental ETS exposure, developing a greater increase in nasal resistance.9

Our study assessed ETS exposure by self-report, which could have resulted in misclassification of some subjects. Similarly, the observed association between travel-related ETS exposure and ETSattributed symptoms could be influenced by subjects’ beliefs about the health effects of ETS. Furthermore, the prevalence of travel-related ETS exposure among adults with asthma may be different than in the general population. Because adults with asthma may avoid ETS, the prevalence may be even higher in people without chronic respiratory conditions.

The negative public health impact of ETS exposure has been conclusively established.3 Although efforts to prohibit public smoking in California have successfully reduced ETS exposure,5 exposure during travel continues to occur. To further curtail ETS exposure, legislation to prohibit public smoking nationally and internationally should be promoted.


   Footnotes
 
Abbreviation: ETS = environmental tobacco smoke

Supported by National Institutes of Health grants K23 HL04201 (Dr. Eisner) and RO1 HL56438 (Dr. Blanc).

Received for publication December 4, 2001. Accepted for publication March 22, 2002.


   References
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 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 

  1. Sippel, JM, Pedula, KL, Vollmer, WM, et al (1999) Associations of smoking with hospital-based care and quality of life in patients with obstructive airway disease. Chest 115,691-696[Abstract/Free Full Text]
  2. Ostro, BD, Lipsett, MJ, Mann, JK, et al Indoor air pollution and asthma: results from a panel study. Am J Respir Crit Care Med 1994;149,1400-1406[Abstract]
  3. California Environmental Protection Agency. Health Effects of Exposure to Environmental Tobacco Smoke. 1997 Office of Environmental Health Hazard Assessment Sacramento, CA.
  4. Macdonald, HR, Glantz, SA Political realities of statewide smoking legislation: the passage of California’s Assembly Bill 13. Tobacco Control 1997;6,41-54[Abstract]
  5. Eisner, MD, Smith, AK, Blanc, PD Bartenders’ respiratory health after establishment of smoke-free bars and taverns. JAMA 1998;280,1909-1914[Abstract/Free Full Text]
  6. Blanc, PD, Cisternas, M, Smith, S, et al Asthma, employment status, and disability among adults treated by pulmonary and allergy specialists. Chest 1996;109,688-696[Abstract/Free Full Text]
  7. Blanc, PD, Eisner, MD, Israel, L, et al The association between occupation and asthma in general medical practice. Chest 1999;115,1259-1264[Abstract/Free Full Text]
  8. Blanc, P Correction to the scientific record. Chest 2000;118,564[Free Full Text]
  9. Bascom, R, Kulle, T, Kagey-Sobotka, A, et al Upper respiratory tract environmental tobacco smoke sensitivity. Am Rev Respir Dis 1991;143,1304-1311[ISI][Medline]



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