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sr-011910-13f13-F January , 2010 I°i Council Meeting: Santa Monica, California CfTY CLERK'S OFFICE -MEMORANDUM To: City Council From: Councilmember Davis Date: January 12, 2010 13-F: Requesfof Councilmember Davis that staff report on the implementation and effectiveness of the ordinance banning smoking in the common areas ofmulti-family residences and that staff identify any enforcement or other issues that have arisen since enactment of the ordinance. 13-F 1 January ', 2010 ~~ ~~~~ ~~ From: Lula Carmon Sent: Tuesday, January 19, 2010 12:24 PM To: Maria Dacanay Subject: FW: Please pass to council for tonight item 13-F request to speak From: Robert Kronovet [mailto:realtor@kronovet.com] Sent: Tuesday, January 19, 2010 12:22 PM To: Lula Carmon Subject: Please pass to council for tonight item 13-F request to speak TO: City Council Members FROM: Robert Kronovet Santa Monica Rent Board Commissioner DATE: January 19, 2009 SUBJECT: Smoking ban For over an hour on December 3, 2009 in the Rent Board Chambers our tenant neighbors poured out their hearts, relaying the emotional, physical and in some cases life-treating trauma they have been forced to endure without any remedy from the effects of second and third hand smoke in their apartments and condos. They came to the Rent Control Board seeking a helping hand... What did they find? A lack of a second. The good news is that the nascent movement to protect renters in their homes from the health hazards caused by tobacco smoke is not over. It has only just begun. The Rent Control Board has now passed this political hot potato to the City Council in whose hands the health of the city's renters and condominium residents now rest. I will be making our case tonight at City Council in connection with the following agenda. 13-F: Request of Councilmember Davis that staff report on the implementation and effectiveness of the ordinance banning smoking in the common areas ofmulti-family residences and that staff identify any enforcement or other issues that have arisen since enactment of the ordinance. For your reference please find the proposed regulation. FROM: Robert Kronovet, Rent Board Commissioner DATE: November 19, 2009 SUBJECT: Board Discussion items for December 3, 2009 RCB meeting The time has come to put public safety above the rights of smokers. I propose that following regulation: Smoking will be prohibited in individual units and their patio/yard areas of multi-unit, multi-story residences (apartments, condominiums, and townhouses) that share common floors and/or ceilings with at least one other such unit. Landlords will be required to insert no-smoking provisions in any new or renewed residential leases; condominiums will add this regulation to their Covenants, Conditions & Restrictions (CCR's) .Landlords may designate outdoor smoking areas if they are more than 20' away from operable doors or windows used by the public. Smoking in indoor common areas of multi-unit residences is already prohibited by a prior ordinance & regulation, and this new regulation will 1/19/2010 ~ ~ ~~ continued that prohibition. City officials have stated thru ordinance (4.44.040 & Added by Ord. No. 2282CCS § 1, adopted 1 /27!09) that enforcement of the smoking ban will be complaint-driven, and that residents should first attempt to resolve any disputes on their own, before the city becomes involved. First-time violators could be subject to a $100 fine. It also establishes a method through which residents could challenge a neighbor who smokes in a common area, allowing them to seek damages of at least $100 in Small Claims Court. The minimum damages increases to $200 for a second violation that is committed within one year, and to $500 for the third offense within the same period. This proposed ban- mirrors' a current ordinance in the City of Belmont, CA where it has been working very well and public health has been well server Thank you, Robert Kronovet Santa Monica Rent Board Commissioner 1/19/2010 s ~.~-~' ~_~~-l~ Cood evening Santa Nlanica City Council Members, My name is Phillip Paley and I live at 247 Bicknell Avenue with my wife, Marla Mattenson. I wanted to update you about our situation since the enactment of Santa Monica Municipal Code §4.44.040. Here is tlne Backgraund: My wife has lived in our rent controlled building for more than fifteen years. A few years ago a chain-smoking woman moved inta the lower unit in the building next door paying full market value. Our building and the building of the smoker share a common courtyard, small garden plot, and walkway. When this neighbor lights up her cigarette, the smoke fills the common azea and comes directly into our upper unit. We have suffered from her smoking in the common area for the last three years. We have to keep all-our windows closed 100% of the time and the smoke still comes in through the cracks in the windows and doors. We bought an air purifier, which is on 24 hours a day, but it is not effective in eliminating the smoke and against the gases in the second hand smoke. My wife suffers from smoke-related headaches and I have documented breathing problems from this exposure. Now far the Update: After the Santa Monica City Council passed the code, the owner next door immediately took action to sidestep the law and protect his smoking tenant by building a "private patio" in the common area (see pictures). It's ironic that he posted a custom made sign on the front of his building that states no smoking in residential common areas. As you all know, the law allows for individuals to sue in small claims court for tiered damages. We thought seriously to pursue this remedy, however, we don't want money from the offender, we want to breathe freely in our apartment without inhaling cigarette smoke. The current code does not provide any protection from second hand smoke. h1 fact, it punishes non-smoking tenants to spend time and money pursuing legal action. Small claims court is not an effective remedy. Drifting Tobacco smoke in multi-unit dwellings is a nuisance and a scienfifically proven health hazard. We need your help. The current Municipal Code is weak and inadequate. We are pleading with you, our City Council, to strengthen the current law to truly protect citizens from exposure to secorid and third hand tobacca smoke. At the minimum, please consider including private balconies and patios to the code and also consider more effective remedy options such as declaring smoking a nuisance and including city enforcement with fines for people who aze breaking the law. This way one can take a picture of'a neighbor smoking in an illegal location and prove to the city that the neighbor is breaking the law. Thank you for your continued efforts on this very important matter. HE v, M 4C 44 ~'* ~~ '~Y x. U.S. Department of Housing and Urban Development Office of Public and Indian Housing Of#ice of Healthy Homes and Lead Hazard Control SPECLAL ATTENTION OF: Regional Directors; State and Area Coordinators; Public Housing Hub Directors; Program Center Coordinators; Troubled Agency Recovery Center Directors; Special Applications Center Director, Public Housing Agencies; Resident Management Corporations; Healthy Homes Representatives Subject: Non-Smoking Policies in Public Housing NOTICE: PHA-2009- 21(HA) Issued: July 17, 2009 Expires: 7uly 31, 2010 Cross Reference: 24 CFR 903.7(b)(3) 24 CFR 903.7(e)(1) 1. Purpose. This notice strongly encourages Public Housing Authorities (PHAs) to implement nonsmoking policies in some or all of their public housing units. According to the American Lung Association, cigazette smoking is the number one cause of preventable disease in the United States. The elderly and young population, as welt as people with chronic illnesses, aze especially vulnerable to the adverse effects of smoking. This concern was recently addressed by the Family Smoking Prevention and Tobacco Control Act, P.L. 111-31, signed by the President omJune 22, 2009. Because Environmental Tobacco Smoke (ETS) can migrate between units in multifamily housing, causing respiratory illness, heart disease; cancer, and other adverse health effects in neighboring families, the Department is encouraging PHAs to adopt nonsmoking policies. By reducing the public health risks associated with tobacco use, this notice will enhance the effectiveness of the Department's efforts to provide increased public health protection for residents of public housing. Smoking is also an important source of fires and fire-related deaths and injuries. Currently, there is m Departmental guidance on smoking in public housing. 2\Applicability. This notice applies to Public Housing 3. Background. Secondhand smoke, which is also known as environmental tobacco smoke (ETS), is the smoke that comes from the burning end of a cigarette, pipe or cigar, and the smoke exhaled from the lungs of smokers. ETS is involuntarily inhaled by nonsmokers, and can cause or worsen adverse health effects, including cancer, respiratory infections and asthma. The 2006 Surgeon General' s report on secondhand smoke identifies hundreds of chemicals in it that are known to be toxic. The report (The Headth Consequences of Involuntary L*'xposure to Secondhand Smoke) is located at c4ruw.cdc.aov/tobaccoldata statisticstserfindex.htm Secondhand smoke causes almost 50,000 deaths in adult nonsmokers in the United States each year, including approximately 3,400 from lung cancer and another 22,000 to 69,000 from heart disease. Secondhand smoke exposure causes disease and premature death in children and adults who do not smoke according to the U.S. Environmental Protection Agency (EPA) www.eoa Gov/smokefreethealtheffectshtml. There are over 12 million residents who reside in pub&e housing. Residents between the ages of 0-17 represent 39 percent of public haushrg residents. Elderly residents over the age of 62 represent 15 percent of public housing residents. That accounts for at least 54 percent of public housing residents that could be at increased risk to the adverse effects of cigazette smoking. There are also a considerable number of residents with chronic diseases such as asthma and cardiovasculaz disease who are particuIazIy vulnerable to the effects of ETS. Secondhand smoke lingers in the air hours after cigarettes have been extinguished and can migrate between units in multifamily buildings. Based on data from the U.S. Fire Administration (USFA} of the Deparhnent of Homeland Security, there were an estimated 18,700 smoking-material fires in homes in 2006. These fires caused 700 civilian deaths (otl~r than firefighters'), and 1,320 civilian injuries, and $496 million in direct property damage www.nfpa.orelassets(filesfPDF/OS.Smokina.pd£ In multifamily buildings, smoking is the leading cause of fire deaths: 26 percent of fire deaths in 2005 www.usfa.dhs.~ovldownloadslt~dflpublicatianslResidential Structure and Building Fires.pdf 4. Policy Discretion PHAs are permitted and strongly encouraged to implement a nonsmoking policy at their discretion, subject to state and local law. Some PHAs have established smoke-free buildings. Some PHAs have continued to allow current residents who smoke to continue to do so, but only in designated areas and only until lease renewal ar a date established by the PHA. Some PHAs are prohibiting smoking for new residents. According to astate-funded anti-smoking group, the Smoke-Free Environment Law Project of the Center for Social Gerontology, there are over 112 PHAs and housing commissions across the country that have implemented non smoking policies. PHAs should consult with their resident boards before adopting nonsmoking policies at their projects. 5. PHA Plans. PHAs opting to implement anonsmokingpolicy should update iheirPHA plans. According to 24 CFiZ 903.7(e), their plan must include their statement of operation and management and the rules and standards that will apply to their projects when the PHA implements their nonsmoking policy. PHAs are encouraged to revise their lease agreements to include the nonsmoking provisions. If PHAs institute nonsmoking polices, they should ensure that there is consistent application arrong all projects and buildings in their housing inventory in which nonsmoking policies are being implemented. 6. Indoor Air Quality (IAQk According to the U.S. Green Building Council (USGBC), toxin- free building materials used in green buildings help combat indoor air pollution. Good IAQ includes minimizing indoor pollutants. As discussed above, ETS is known to be an indoor air pollutant; as a result it would be difficult for a PHA to achieve good IAQ in its buildings if residents are allowed to smoke, especially indoors. I}uring construction or renovation of projects, PHAs should consider actions such as installing direct vent combustion equipment and fireplaces; providing for optimal, controlled, filtered ventilation and air sealing between living areas and gazage or mechanical azeas, and the use of paints and other materials that emit no or low levels of volatile chemicals (volatile organic compounds or VOCs). Since 65 percent of the public housing inventory was built prior to 1970, it would be hard for a PHA to implement retrofits that could improve IAQ significantly, unless renovation was scheduled. Also, if a PHA does conduct renovations to improve IAQ without also implementing a nonsmoking policy, the IAQ benefits of the renovation would not be frilly realized. A nonsmoking policy is an excellent approach for those PHAs that aze trying to achieve improved IAQ without the retrofit costs. 7. Maintenance. It is well known that turnover costs are increased when apartments are vacated by smokers. Additional paint to cover smoke stains, cleaning of the ducts, replacing stained window blinds, or replacing carpets that have been damaged by cigarettes can increase the cost to make a unit occupant ready. View the Sanford Maine Housing Authority case study at http:(Iwww. smokefreeforme.or~/landlord.oho?sra~e=Save+Money°!°2C%3 Cbr%3ESave+Yaur+B uildin . 8. Smolan¢ Cessation National SnaPOrt. Because tobacco smoking is an addictive behavior, PHAs that implement nonsmoking policies should provide residents with information on local smoking cessation resources and programs. Local and state health departments are sources of information on smoking cessation; seethe American Lung Association's (ACA's) Web page on State Tobacco Cessation Coverage www.lunsusa2.or~Icessation2 for information on cessation programs, both public and private, in all States and the District of Columbia. The National Cancer Institute's Smoking Quit Line can be called toff-free at 877-44U-QIJPF (877-448-7848). Hearing- or speech-challenged individuals may access this number through TTY by calling the toll-free Federal Relay Service at 800-877-8339. PHAs that implement nonsmoking policies should similarly be persistent in their efforts to support smoking cessation programs for residents, adapting their efforts as needed to local conditions. 9. Further Information For furthe r information related to this notice, please contact Dina Elani, Director, Office o£Public Housing Management and Occupancy Division at (202j 402-2071. (s/ /s/ Sandra B. Henriques Jon L. Gant, Assistant Secretary for Public and Indian Director, Office of Healthy Homes and Housing Lead Hazard Control Smokefree pissing rinance Checklist Increasingly, more California communities want to unpxove the health of restdents bg ereatatg sntokefree multi unit haustng: T'he options fisted below are part of the TechmcaL Asststaace Legal Center's (TALC'S) Model California Ordinance I~egufating Smokang in Mulh Unit lteridenczc; available at www.phlpnet.orgJtobacco-control Policy provisions that TALC highly recommends are checked (Q); those that are not checked are addtnonal pptions a community may want to ttclude. Contact TALC far help drafting an ordinance based on your commumt~s choices; 'IY PE OF MULTI-ITNTT HOUSING REGULATED Q All typer of pxopexty contatninza 2 or more units Q Except hotels and motels ^ Egeept smgIe-faintly homes with ^ Except condaxniniums ^' Except mobile home parks an in law of second unit- ^ Except WFIERE SMD%ING IS PROFQBYTED 'Q Common Areas of all tyyier of regulated mule unit housing Q Indoor common areas. Q Outdoor common areas Q Except For designated "smoking areas" that meet certain criteria Q L)utdoor Smokefree Buffer Zones for all tyfies of regulated multi unit housutg Q r'~nvwhexe on the progexty of the multi unit housing conplex, including bateantes ar patios, vnthin 25 Feet of an .enclosed area where smoking as prohibited (eg., a nonsmoking unit) ^.On neighboring property wuhin 25 feet of an enclosedarea where smoking is prolubtted.. ^ (1n the balcony, pang; ar deck of any unit, including smoking allowed amts Q New Urtits Q 100°f° of all. new units in add tyjier of regulatedmulti unit housing ^ Allow a builder to designate up to 10% of units as smoking-allowed Q Existing Units ^ 100% of eazrtind units in a condominium complex: (ordinance must designate aIt eondomini,im units as nonsmoking because ofpracncal and potential legal issues in local government selecting which amts maybe smoking allowed) ^ Allow a homeowners' association to'vote to designate up to 20% of units as smoking allomed Q 100% of exis[zng units in a rental camj~lex Q rlllow a landlord to designate up to 20°!0 of units as smoking allowed. Q Require nonsmoking amts be grouped together and physically separated from. amts where smoking may be allowed Q phase in period: smoking m a designated nonsmoking unit violates the law one year after the ordinance takes effect ADDITIONAL PROVISIONS 8 Require no smolonglease terms in rental anoreements.. E( Require Yandlord to disclose where smokio£; is allowed Requite landlords to subxnie a diagram of smoking and nonsmoking amts to (insert name of depamnent) 0 Declare"secondhand smoke a nuisance ^ Only in a restdenttal setting ^ Exclude medical marijuana from regulation by the ordinance ENFORCE113ENT 0 Designate that the ordinance will be enfozced by but also enforceable by a peace officer of code enforcement officer Q Declare violations based on itlegalrmaksng to be infractions with a fixed ftne amount of $ _ (cannot be more than $100) Declare that violation of the ordinance consnmtes a nmsance rillow private citizens to seek an injunction (an order to snip violations} and(or money damages against individuals who violatethe ordinance www.phlpnet.org talc@phlpnex.org (510) 3023380 December 2009 ~ 3-1= -/~- Jan. 19, 2010 Dear City Council Members and Staff, For the past eight years I have been a resident at 2800 Neilson Way, commonly known as the SHORES. I have been a practicing pediatrican in Southern California for 36 years. I am currently working with infants who were born prematurely and have respiratory difficulties. For identification purposes only, I am Chair of Substance Abuse #or the American Academy of Pediatrics. I am an assistant clinical professor at UCLA , on staff at Gedars and certified with the American Academy of Pediatrics. I also volunteer at the Venice Family Clinic. I have prepared copies for you of PEDIATRICS the official journal of the American Academy of Pediatrics specifically an article on "Association Between second hand Smoke Exposure and Sleep Patterns in Children" which was published yesterday and contains very important new information. I'm asking the council to increase measures to implement the protection of children that are affected by the seeping of second hand into their bedrooms. This second hand smoke effects their breathing from the smoke from balconies, common areas and adjacent apartment units. California EPA law already states that second hand smoke is a cancer causing agent and reproductive toxin. Therefore, I think the council, should also seriously consider designating areas of smoke-free units within apartment complexes. Please consult with the American Academy of Pediatrics Richmond Center whose email address is nlcnrnondcenter~aao.org. Their phone # is 585 275 1843. Their mission is to improve child health by eliminating childrens' exposure to tobacco and second hand smoke. I thank you for your t~ i1me/. S~ c, Trisha Roth, M,D. , F.A.A.P. Associations Between Secondhand Smoke Exposure and Sleep Patterns in Children -Yolton et al., 10.1542/peds2009-0690 -- Pediatrics 1/19(10 9:53 AM Advertising Disclaimer PEDIATRICS` fr Y f D 4 i Published online January 18, 2010 ~ PEDIATRICS (doi:10.1542/peds.2009-0690) ARTICLES ~ Advanced Search Associations Between Secondhand 1 Full TeM (PDF) Smoke Exposure and Sleep Patterns in Submit a response r PEDIATRics Children 1 Alert me when this article is cited g In 1 Alert me when eLetters are posted bscribe/Renew Kimberly Yolton, PhDa, Yingying Xu, MS, MAa 1 Alert me if a correction is posted Inage My Account Jane Khoury, PhDD, Paul Succop, PhD`, .S Feeds Bruce Lanphear, MD, MPHd, Dean W. Beebe, PhDe ` E-mail this article to a friend . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iTITUTIONS and Judith OWenS, MD 1 Similar articles in this journal Inage My Account a Divisions of General and Community Pediatrics and 1 Similar articles in PubMed ovate My Subscriptions bBiostatistics and Epidemiology, and 1 Alert me to new issues of the journal ~rarians Portal eBehavioral Medicine and Clinical Psychology 1 Add to My File Cabinet °---° ------------------------ , Department of Pediatrics, Cincinnati Children's Hospital F Download to citation manager :THORS Medical Center, Cincinnati,'Oh10; > Request Permissions thor Guidelines `Department of Environmental Health, University of - pyright Form Cincinnati, Cincinnati, Ohio; 1 Citing Articles via CrossRef itorial Policies dFaculty of Health Sciences, Simon Frasier University -i-funded Articles and British Columbia Children's Hospital, Vancouver, bmit and Track My Canada; and F Articles by volton, K. inuscript fDepartment of Pediatrics, Brown University, 1 Amides by ovens, ~. _..._ ....................... Providence, Rhode Island URNAL INFORMATION _ OBJECTIVES The objective of this study was to 1 PubMed Citation ~neral Information out-the Journal investigate the relationship between exposure to 1 Articles by Yolton, K. itorial Board secondhand smoke SHS and child slee ( ) p patterns /Articles by Owens, J. r News Media among a group of children with asthma who were rAdvertisers exposed regularly to tobacco smoke at home. ---- METHODS We studied 219 children who were enrolled ~~~ ` f -- ® ` ~' '~ RvICES in an asthma intervention trial and were exposed What's this? rmissions regularly to SHS. Serum cotinine levels were used to prints measure exposure to tobacco smoke, and sleep patterns were assessed through parent reports LATED~RESOtiRCES~ using the Children's Sleep Habits Questionnaire. Covariates in adjusted analyses included gender, age, race, matemal marital status, education, and income, prenatal tobacco exposure, matemal .P Journals depression, Home Observation for Measurement of the Environment total score, household density, P asthma severity, and use of asthma medications. dJobs diatrics' Web Site Tools RESULTS Exposure to SHS was associated with sleep problems, including longer sleep-onset delay {P = .004), sleep-disordered breathing (P = .02), parasomnias (P = .002), daytime sleepiness http://pediatrics.aappublications.org/cgilcontent{abstratt/peds.2009-0690v1 Page 1 of 2 Associations Between Secondhand Smoke Exposure and Sleep Patterns in Children -- Yolton et al., 10.1542/peds.2009-0690 -- Pediatrics 1/19/10 9:53 AM (Y = .UZY), ana overau sleep alsluroance (r = .vuuz~. i ~~ "'7a 'e~~ '' CONCLUSIONS We conclude that exposure to SHS is associated with increased sleep problems S1GN UP how FEE among children with asthma. Key Words: passive smoking • environmental exposure • sleep • child • asthma Abbreviations: HOME, Home Observation for Measurement of the Environment Accepted Aug 3, 2009. I~~CiteULike '~ - Connotea ^ Del.icio.us ---- Digg ®Facebook ~ Reddit ~Technorati ~ Twitter What's this? a....x•..a~ Sti.`. American Academ}~ of Pediatrics '; os..?:cnT r.n ~ro r!!r. urn;.n: oc .a'_t. c!ntoBCS- '^~~ :"+. ~+~ Contact AAP ~ Privacy Statement ~ About :k here for faster international access http:/lPediatrics.aappublications.org/cgi/content/abstraa(peds2009-0690v1 Page 2 of 2 PEDIATRICS Associations Between Secondhand Smoke Exposure and Sleep Patterns in Children Kimberly Yolton, Yingying Xu, Jane Khoury; Paul Succop, Bruce Lanphear, Dean W. Beebe and Judith Owens Pediatrics published online Jan 18, 2010; DOI: 10.1542/peds2009-0690 The online version of this article, along with updated information and services, is located on the World Wide Web at: http:!/www.pediatrics.org ~, PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevazd, Elk Grove Village, Illinois, 60007. Copyright ©2010 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005.Online ISSN: 1098-4275. American Academy of Pediatrics DEDICATED TO THE HEALTH OF ALL CHILDREN" ~ Associations Between Secondhand Smoke Exposure and Sleep Patterns in Children AUTHORS: Kimberly Yolton, PhD,' Yingying Xu, MS, MA,a Jane Khoury, Ph D,° Paul Succop, Ph0,° Bruce Lanphear, MD, MPH," Dean W. Beebe, PhD,e and Judith Owens, MD' Divisions of°General and Community Pedatrics and °Biostatistics and Epidemiology and °Behaviarol Medicine artd Clinical Psychology, Department ofPediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; 'Department of Environmental Health University ofCincinnati, Cincinnati, Ohio; °Faculty afNeaRh Sciences, Simon Frasier University and British Columbia Children's Hospital, Vancouver, Canada; wd'Oeporbnent of Pediatrics, Brawn University; Providence, Rhode Island KEY WORDS passive smoking, environmerrtal exposure, sleep, chiltl, asthma ABBREVIATIONS CSHQ-Children's Sleep Habits Questionnaire OR-odds ratio CI-confidence interval SHS-secondhand smoke HOME-Home Observation for Measurement ofthe Environmerd vrrow.pediatrics.org/cgi/doi/10.1542/Peds2009-0690 doia o.1542/peds.zcos-0sso Acceptetl for publication Aug 3, 2009 Address correspondence to Kimberly Yolton, PhD, Cincinnati Children's Hospital Medical Cemer, Division of General and Community Pediatrics, 3333 Burnet Ave. ML 7035, Cincinnati. OH 45229-3039. E-mail: kimberly.yalton@cchmc.org PEDIATRICS (ISSN Numbers: Print, 00374005; Online, 1098-4275). Copyright ©2070 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have na financial relationships relevant to this article to disclose. WHAT'S KNOWN ON THIS SUBJECT: Adult and adolescent smokers report difficulties with sleep. Young children who are exposed to tobacco smoke have poorer sleep quality. Children with asthma report more sleep problems and are more sensitive to the respiratory effects of tobacco smoke. WHAT TNIS STUDY ADDS: We report significanrt associations between SHS exposure, as measured with a biological marker (serum cotinine levels), and sleep problems in children with asthma. Reduction in SHS exposure is an area with the potential for significant impact in the pediatric population. OBJECTIVES: The objective ofthis study wasto investigatethe relation- ship between exposure to secondhand smoke (SHS) and child sleep patterns among a group of children with asthma who were exposed regularly to tobacco smoke at home. METHODS: We studied 219 children who were enrolled in an asthma intervention trial and were exposed regularly to SHS. Serum cotinine levels were used to measure exposure to tobacco smoke, and sleep patterns were assessed through parent reports using the Children's Sleep Habits Questionnaire. Covariates in adjusted analyses included gender, age, race, maternal marital status, education, and income, prenatal tobacco exposure, maternal depression, Home Observation for Measurement of the Environment total score, household density, asthma severity, and use of asthma medications. RESULTS: Exposure to SHS was associated with sleep problems, in- cluding longer sleep-onset delay (P = .004), sleep-disordered breath- ing (P= .02), parasomnias (P= .002), daytime sleepiness (P = .022), and overall sleep disturbance (P= .0002). CONCLUSIONS: We conclude that exposure to SHS is associated with increased sleep problems among children with asthma. Pediatrics 2010;125:e261~268 Appropriate sleep quality and quantity are increasingly being recognized as critical elements for many aspects of child health and development. For children, inadequate sleep has been linked with poor school performance,' somatic complaints,' behavior prob- lems,z-5and mental health problems.'•6 In addition, sleep problems during childhood are associated with in- creased incidence of anxiety and de- pression, aggressive behaviors, and attention problems in adulthood, which suggests a lasting impact of sleep problems on mental health. Poor childhood sleep also predicts the development of obesity and its associ- ated morbidities,e•9 which indicates an important influence on health outcomes. More than 25% of children experience some type of sleep problem during childhood.'•'o-12 Among children with asthma, the prevalence of sleep problems is higher, with 40%to 60% having some difficulty.13•'A Children with asthma are nearly 4 times more likelyto experience sleep-disordered breathing,15 which results in sleep disruption and decreased sleep effi- ciency,'s reduced sleep quality, in- creasednighttime activity levels," and more difficulties with daytime sleepi- ness.'s•18 Sleep efficiency has been shown to improve with effective treat- ment of asthma symptoms,'s but even children with clinically stable asthma have worse sleep quality and more daytime sleepiness than do children without asthma.19 Tobacco exposure is a risk factor for sleep problems in adolescents and adults. Cigarette smoking is associ- ated with changes in sleep architec- ture, with smokers experiencing longer latency to sleep initiation and lighter sleep.20 Adult and adolescent smokers report more sleep problems, such as trouble initiating sleep, main- taining sleep, difficulty waking, and daytime sleepiness.zt-za Women who smoke during pregnancy are more likely to report insufficient sleep, diffi- culty initiating sleep, early morning waking, short sleep duration, snoring, and excessive daytime sleepiness, compared with pregnant women who do not smoke. Interestingly, women who are nonsmokers but are exposed to secondhand smoke (SHS) during pregnancy also report more difficul- ties with sleep, including insufficient sleep, difficulty initiating sleep, and short sleep duration, compared with those not exposed 25 This effect of SHS on sleep in adult women raises concerns about the po- tential impact on children whose fam- ily members smoke. There is little re- search on the influence of tobacco smoke exposure on sleep patterns in childhood. Young children who are ex- posed totobacco smoke either prena- tally or postnatally are reported to have poorer sleep quality26 and more symptoms ofsleep-disordered breath- ing,z' compared with those who are not exposed. Because tobacco smoke is a known contributor to asthma se- verity,z~0 exposure to SHS may have a particularly marked effect on the sleep of children with asthma. Although this possibility has received little empirical investigation, SHS exposure has been associated with increased night wak- ings in children with asthma 3t A major limitation ofthese studies linking SHS and sleep difficulties in childrenzs,zza, is the fact that they relied on parent reports of exposure, instead of more- precise and more-objective biological markers of tobacco exposure. The objective of this study was to ex- amine the relationship between SHS exposure and sleep patterns among a group of children with asthma. We used a biomarker of tobacco expo- sure, serum cotinine levels, to quan- tify exposure objectively and a vali- dated pediatric sleep survey32 to characterize sleep patterns. We hy- pothesized that children with asthma who were exposed to higher levels of SHS would exhibit more sleep prob- lems, as reported by parents, com- pared with children with lower levels of exposure. METHODS This study used the Cincinnati Asthma Prevention Study, an asthma interven- tiontrialbased onenvironmental mod- ifications to the home in the form of high-efficiency particulate air clean- ers, and outcomes focused on asthma symptoms, health care utilization, and pulmonary function. for the current study, SHS exposure, child sleep pat- terns, and potential covariates were measured before initiation of the asthma intervention. Recruitment and enrollment proce- dures forthe 6-to 12-yearvold children are described in detail elsewhere Briefly, all children in the sample had physician-diagnosed asthma that had been treated within the previous year and exposure to SHS from ?5 ciga- rettes per day at home, according to parent report. Children were identified on the basis of hospital and clinic bill- ing records, and parents of 1678 chil- drenwere contacted for completion of a screening survey and request for participation, it eligible. Children were excluded if they had other respiratory diseases, heart disease, mental retar- dation, or other serious conditions barring participation in the study. Of the 348 eligible participants, 232 en- rolled and completed the main study (67% participation rate), and 219 had complete data pertinentto the current study and were retained forthe analy- sis. Protocolswereapproved bythe in- stitutional review board. We collected detailed survey data re- garding the child's daily exposure to SHS in the home,.car, and other loca- tions, including hours of exposure, number of cigarettes per day, whether the child was in the same room during smoking, and whether windows were open during car exposure. SHS expo- surealso was measured objectively by using serum cotinine levels detected in samples collected at the baseline home visit, which represent our pri- marymeasure of exposure. cotinine, a metabolite of nicotine, is a reliable biomarker of exposure to tobacco smoke.36 Serum levels provide ashort- term view of exposure over the previ- ous 48 to 72 hours. However, because of stability of exposure patterns over time, aone-time cotinine measure- ment is considered representative of typical daily exposure36~otinine levels in serum were measured by the Cen- ters far Disease Control and Preven- tion with published methods involving high-performance liquid chromatog- raphy linked to atmospheric-pressure chemical ionization-tandem mass spectrometry. We applied a logarith- m icbase 2 transformation for analysis of serum cotinine levels because of the skewed distribution of the raw data. This provides for simpler inter- pretation of the coefficients from the regression analyses, in which there is an increase in the sleep scale equal to the coefficient for log cotinine level for each doubling of the cotinine level. The Children's Sleep Habits Question- naire (CSHQ)3 was used to measure child sleep patterns within the previ- ous 2 weeks, as reported by the pri- mary caregiver. The CSHQ yields a to- talsleep disturbance score and scores for 8 scales (ie, bedtime resistance, sleep-onset delay, sleep duration, sleep anxiety, night wakings, parasomnias, sleep-disordered breathing and daytime sleepiness). This instrument is used in clinical and research settings to pro- vide abroad description of child sleep patterns. Internal consistency mea- sures for the entire scale are high (a = 0.68 for a commun ity sample and ~ = 0.78 for a clinical sample), and test-retest reliabilities among the scales are high (r= 0.62-0.79).Atotal CSHQ score of ?41 has sensitivity of 0.80 and specificity of .0.72, properly classifying 80% of a group with clini- cally relevant sleep disorders. To en- sure uniform thorough completion, this measure was administered in an interview in which caregiver re- sponses were recorded by a trained research assistant. Asthma severity was reported as mild, moderate, severe, or very severe by the child's caregiver. Severe and very severe categories were combined be- cause of small group sizes. Parent report of asthma symptoms is an ef- fective means of characterizing child asthma and is not enhanced by asthma diaries or pulmonary function test- ing.36 Parents also reported asthma medication use by the child, includ- ing use of short-acting bronchodila- tors, long-acting inhaled steroids, and orally administered steroids prescribed for treatment of acute exacerbations. Other measured covariates were ma- ternaldepression (Beck Depression In- ventory Ip31and quality ofthe home en- vironment, measured with the Home Observation for Measurement of the Environment (HOME) instrument for elementary school-aged children 3s The HOME instrument is primarily an observational tool that assesses the quality of the home environment, in- cluding physical characteristics, vari- ety of stimulation, and nurturing be- havior from the parent, and was completed at a 12-month follow-up visit. For 14 participants, this assess- ment was missing and imputed values generated with SOLAS 3.0 (Statistical Solutions, Cork, Ireland), on the basis of age, race, and gender, were used. Univariate analyses involved inspec- tion of frequencies and estimation of means and associated SDs. Because of nonnormal distributions, serum cotin- ine levels are reported as geometric means and 95% confidence intervals (Cls), and household income is re- ported as median and 25th and 75th percentile values. We used linear re- gression far the daytime sleepiness and total sleep disturbance scales. The distributions of the other sleep scales reflected varying degrees of nonnor- mality; therefore, responses were di- chotomized, at approximatelythe 75th percentile value, and logistic regres- sion was used. For each outcome mea- sure, 3 models were developed, to reflect (1) the simple bivariate associ- ation between exposure and sleep, (2) the association after adjustment for all covariates (age, gender, race, ma- ternal smoking during pregnancy, marital status, maternal education, household income, household density, number of siblings, maternal depres- sion,HOME score, asthma severity, and asthma medication use), and (3) the association after adjustment for im- portant covariates, representing the most statistically parsimonious final model. For the final models, age, gen- der, and asthma severity were re- tained irrespective of statistical signif- icance.Other covariates were retained if they accounted for significant vari- ance onthe given sleep scale (P<.OS). Also, if removal of the covariate from the model was associated with a > 10% change in the regression coeffi- cient for serum cotinine levels, then it was retained in the model. SAS 9.1 (SAS Institute, Cary, NC) was used for all analyses. RESOLTS Descriptive information on the sample is summarized in Table 1. The mean age ofthe subjects atthe baseline visit was 9.4 years. Sixty-one percent of the children were boys, and 56%were re- ported to beblack. Children in the sam- ple were exposed to a median of 13 cigarettes per day in their homes, as `;.~__ : Sample Characteristics (N = 219) Age, mean ~ SD, Y 9.4 ! 7.8 Male, n (%) 134 (612) Race, n (%) Black 122 (55.7) White 92 (42.0) Other 5 (2.3) Parent education, n (%) High school graduate or less 143 (65.3) Any college 76(34.7) Parent marital status, n (%) Marrietl or living with someone 91 (41.6) Divorced, separated or witlowed 37 (16.8) Single, never marrietl 91 (41.6) Household income, metlian (interquartile range), $ 25 000 (15 000-45 000) Asthma severity, n (%) Mild 51 (23.2) Moderate 105 (48.0) Severe/very severe 63 (28.8) Maternal smoking during pregnancy, n (%) None - 73 (33.3) Until pregnancy recognition 32 (14.6) Throughout pregnancy 114(521) No. of cigarettes smoked in home daily, median (irRerquartile range) 13 (9-20) Serum cotinine level Geometric mean (95%C0, ng/mL 1.16 (0.10-13.01) Median (irRerquartile range). ng/mL 1.45 (0.56-2.69) HOME score, mean -!~ SD 46.9 r 8.1 Maternal tlepression score, mean ~ SD 12.4! 9.9 Behavior Assessment Sys[emfar Chiltlren-2 score within clinical range 270), n (%) Extemalaing symptoms 41 (18.8) I(rternalizing symptoms 58 (26.6) Behavior symptoms 46 (21.1) Sleep pattern score, mean ~ SO Bed resistance 8.9 ~ 2.7 Sleep-0nset delay 1.6 ~ 0.8 Sleep tluretion 4.4 ~ 1.7 Sleep anxieTy 5.7 -t 1.8 Night waking 4.3 i 1.3 Parasomnias _ 9.6 -t 2.1 Sleepdisordered breathing 42 ~ 1.4 Daytime sleepiness 15.5 "_- 3.3 Total sleep disturbance 51.6 "_- 8.2 Total sleep tlisturbance raw score of?41, n (%) 203 (927) reported by their parents, andthe geo- metric mean serum cotinine level for the sample was 7.16 ng/mL. The corre- lation between serum cotinine levels and parent-reported exposure was 0.39 (P < .0001) for the full sample. Mean values for overall sleep distur- bance and sleep scale scores for children in our sample fell between the clinical and control samples re- ported by Owens et al 321nternal con- sistency for the sleep measure also was comparable to the findings of Owens et a132 Surprisingly, 93% of the children in the sample had a CSHQ total sleep disturbance score 241) that would be considered clin- ically relevant. The mean sleep time reported by parents was 9.6 hours per night. In bivariate analyses, the associations between the logarithm of serum cotin- ine levels and child sleep patterns were significant for bedtime resis- tance, sleep anxiety, parasomnias, sleep-disordered breathing, daytime sleepiness, and total sleep distur- bance but not for sleep-onset delay or sleep duration (Table 2). There was no association between total duration of nighttime sleep and serum cotinine levels. In multivariate analyses including all potential covariates of child sleep pat- terns, we found that higher levels of SHS exposure were significantly asso- ciated with higher scores (ie, more problems) on the sleep-onset delay, parasomnias, daytime sleepiness, and total sleep disturbance scales. Final models, including only covariates that had a relationship with the sleep scale of interest or affected the coefficient for cotinine levels, revealed significant associations between SHS exposure and increases insleep-onset delay, para- somnias, sleep-disordered breathing, daytime sleepiness, and overall sleep disturbance (Table 2). Several covariates remained in our final models because of associations with sleep scales. Increasing age was significantly associated with de- creased bedtime resistance, more problems with sleep duration, less sleep anxiety, and lower overall sleep disturbance. More-severe asthma was associated with more problems with sleep duration and more-frequent night wakings. Maternal smoking during pregnancy was associated with decreased sleep-onset delay.A nonmarried parent was associated with fewer parasomnias and in- creased daytime sleepiness. Lower family income was associated with de- creasedsleep duration and decreased daytime sleepiness. Higher levels of maternal depression were associated with more-frequent parasomnias, increased daytime sleepiness, and greater overall sleep disturbance. More siblings and increased housing density were associated with de- creased sleep-disordered breathing. Finally, the use of long-term inhaled asthma medications was associated with fewer parasomnias. ,..,,_= 2 Associations Between Serum Cotinine Levels (Intlependerrt Variable) and Children's Sleep (Dependerrc Variable) in Logistic and Multiple Regression Analyses (N= 219) Sleep Scale (Cutoff Poird) Bivariate Association Between Serum Cotinine Levels and Sleep Outcomes Full Model ofAssaciation Between Serum Cotinine Levels and Sleep Outcomes Including All Covariates Final Model of Association Between Serum Cotinine Levels and Sleep Outcomes Including Significam Covariates OR ors (95%CO P OR Ors (95%Cp P OR ors (95%Cp P Betl resistance (>10) 1.29 (1.09-7.53) .003 7.34 (0.95-1.88) .093 L21 (0.995-1.47) .056 Sleep-0nset delay 22) 7.07 (0.92-1.24) .39 1.50 (1.08-2.06) - .014 1.53 (1.15-2.03) .004 Sleep duration (?5) 7.00 (0.86-1.77) .98 1.19 (0.87-1.63) .27 1.12 (0.92-1.37) .24 Sleep anxiety (?7) 1.28 (7.07-1.53) .006 0.90 (0.65-1.24) .57 1.06 (0.87-1.38) .68 Night wakings (?5) 1.09 (0.93-1.28) .2S 1.70 (0.81-1.50) .54 1.09 (0.92-7.31) .32 Parasomnias (?72) 1.62 (1.23-2.12) .0005 1.91 (1.09-3.34) .023 7.95 (1.36-279) .0002 Sleepdisortleretl breathing 25) 1.29 (1.08-7.54) .005 1.33 (0.94-7.89) .71 7.26 (7.04-7.52) .02 Daytime sleepiness 0.40 (0.15-0.64) .002 0.51 (0.08-0.94) .021 0.33 (0.05-0.6U .022 Total sleep disturbance 1.40 (0.81-7.99) ~ <0007 7.42 (0.37-2.47) .009 7.14 (0.54-1.74) .0002 Chiltl age, gender, and asthma severitywere included in all analyses. other covariates were includetl iftheywere statistically relevant t°thesleepscaleaf interes[antl inclutletlthefollowing consitlerations: maternal race. martial status, etlucation, income, smoking during pregnancy, and depression, HOME inventory total score, househaltl tlensTy (house volume per persons), number of siblings, and use of asthma metlication Onclutling short-acting inhaletl metlicines, long-aging inhaletl metlicines, and orally administeretl s[ercitls). Muttivanate regression analyses were used far analysis of daytime sleepiness and total sleep tlisturbance (s repor[etl); all other analyses usetl logistic regression analyses of dichotom¢etl sleep scales (bR rePar[etl). We found Cotinine level-gender inter- actions forthe sleep-onset delay (odds ratio [OR7: 0.63; P = .017) and sleep anxiety (OR: 7.47; P = .05) scales; therefore, we performed gender- stratified regression analyses for those scales, control ling forthe covari- ates retained in the final models for the full sample. For boys, a statistically significant relationship was found be- tween serum Cotinine levels and higher scores for sleep anxiety (OR: 1.54; P = .003). For girls, a statistical ly significant relationship was found be- tweenserum cotininelevels and sleep- onset delay (OR: 1.54; P = .008). DISCUSSION For children with asthma, we found that SHS exposure was associated with greater parent-reported sleep problems. Specifically, as SHS expo- sureincreased,parents reported that their children had longer delays in sleep onset, more-frequent parasom- nias and sleep-disordered breathing, increased daytime sleepiness, and greater overall sleep disturbance. Two sleep scales showed significant gendercotinine level interactions. In regression analyses stratified accord- ingto gender,greaterexposuretoSHS was associated with greater sleep anx- iety in boys and greater sleep-onset delay in girls. SHS exposure was associated with in- creased incidence of parasomnias in this sample of children. Parasomnias reflect partial arousal from either non- rapid eye movement or rapid eye movement sleep and, although usually benign, can be highly distressing to children and their families. More than 80% of preschoolers experience para- somnias, but their incidence de- creases with age 39 Adult men who smoke report more nightmares and disturbing dreams than do men who do not smoke, but there has been no reported association for women2d Boys in our study experienced greater sleep anxiety with increasing SHS ex- posure. Nighttime fears are reported by up to 79% of S-to 16-year-old youths. In contrast to our findings, however, they have been reported more fre- quently among girls (72°k) than boys (55%) m for girls in our study, greater SHS exposure was associated with greater sleep-onset delay, which is con- sistent with reports that both men and women who smoke cigarettes have in- creased difficulty initiating sleep^t No other studies have investigated the rela- tionship between SHS and sleep-onset delays among children. The exact mechanism through which SHS exposure may affect children's sleep is not clear. We briefly explore 3 possible explanations, that is, exacer- bation of respiratory symptoms, nico- tine arousal mechanisms, and symp- toms of abstinence. In adults, smoking is known to exacerbate respiratory disorders such as obstructive sleep apnea?4d2 and SHS exposure has been associated with increased snoring in pregnant women 25 Among children, parent-reported maternal smoking is associated with increased snoring, and nighttime respiratory symptoms are exacerbated by exposure to SHS?' Indeed, higher levels of SHS exposure were associated with more sleep- disordered breathing among children in our study. It is likely that SHS exposure acts as an upper airway irritant, increasing symptoms of sleep- disorderedbreathing and thus contrib- uting to overall sleep disturbances among children with asthma. Although adolescent and adult smokers report disturbances in sleep,-X61-°3 a clear causal relationship between to- bacco and sleep disorders has been difficult to establish 4z Nicotine is a stimulant that may contribute to in- creased arousal and attention among smokers, likely by stimulating neuro- transmission ofacetylcholine and trig- gering activation of the dopaminergic system in the brain dz"' Nicotine is as- sociated with altered sleep architec- ture, resulting in reduced sleep time and efficiency, longer sleep latency, lighter sleep, and reduced rapid eye movement sleep.20.as Frequent night wakings among smok- ers often are attributed to withdrawal during sleep. During the early stages of smoking abstinence, adult smokers experience difficulty falling asleep, re- duced sleep efficiency, and longer la- tency to rapid eye movement sleep.°6 Colrain et al°' reported increased night wakings and sleepiness as the most-consistent findings of research on smoking cessation. Insomnia, sleep disturbance, and anxiety also are symptoms of nicotine withdrawal listed in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.48 These symptoms in many ways resemble those reported in our sample. It is possible that children ex- posed to SHS experience a degree of nicotine withdrawal during sleep, which results in disruptions in the normal sleep process. Although with- drawal symptoms among children ex- posed to SHS have, to our knowledge, not been noted in the literature, sev- REFERENCES 7. Paavonen EJ, Aronen ET, Moilanen I, et al. Sleep problems of school-agetl chiltlren: a complementary view. Arta Paedia[r. 2000: 89(2):223-228 2. Aronen ET, Paavonen EJ. Fjallberg M, Soin- inen M, Torronen J. Sleep and psychiatric symptoms in school-age children. J Am Acad Child Adolesc Psychiatry 2000;39(4): 502-508 3. Owens JA, Maxim R, Nubile C, McGuinn M, Msal I M. Parental and self-report of sleep in chiltlren with atterdion-deficit/hyperactivity eral studies presented evidence that newborns who were exposed prena- tally to tobacco experienced nicotine withdrawal shortly after birth?' This area requires further study. SHS exposure results in a much smaller amount of nicotine intake than active smoking. Studies of SHS effects on sleep have included re- ports of sleep disturbances among adult men,d1 pregnant women 25 and preschool-aged children?fi which in- dicatesthat even small amourrts of ex- ppsure to nicotine, as would occur in SHS exposure, are sufficient to affect sleep adversely. Our study contributes additional evidence that SHS affects sleep among school-aged children with asthma. This study is not without Ii mitations. AI I children in the study had asthma, and the results may not be generalizable to populations of children without asthma. 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Pediatrics. 2009;123(5).Availabie a[:www.pediaatics.org! cgi/corRent/full/123/5/e857 only. Additional study in this area should include use of child-reported sleep problems and additional mea- sures of sleep patterns, such as polysomnography, actigraphy, or de- tailed sleep diaries. Finally, we had no information on prematurity inthis sample, which could be an important contributor to sleep problems sass CONCLUSIONS Among children with asthma, expo- sure to SHS affects sleep negatively, as evidenced by greater sleep-onset delays, more-frequent parasomnias, more sleep-disordered breathing, in- creased daytime sleepiness, and greater overall sleep disturbance. The consequences of inadequate sleep in children are not trivial. Sleep distur- bances have been linked with in- creased behavior problems,z~ mental health problems,t6 and poor school performance' in children. 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Beebe and Judith Owens Pediatrics published online Jan 18, 2010; Tlli. in ~i-.... ___ Updated Information including high-resolution figures, can be found at: & Services http:/hvww.pediatrics.org Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.pediatrics.org/mi sc/Perrvissionsshtml Reprints Information about ordering reprints can be found online: http: //www.pediatrics.org/mi sc/repri nts shtml American Academy of Pediatrics ~~yy~~``~~\\\\ DEDICATED TO THE HEALTH OF ALL CHILDREN" ~~ a