Asthma in the US is widespread, with incidence rates and morbidity increasing dramatically over the last 2 decades. The cost of asthma-related morbidity and mortality is large. There is substantial and convincing evidence that environmental factors are associated with asthma exacerbation, and more limited evidence that environmental factors play a role in the development of asthma. Educational interventions, which include an avoidance of 'triggers' or focus on reducing exposure to cigarette smoke, have been shown to be moderately effective. While various interventions have been shown to reduce environmental exposures, fewer studies have collected sufficient information on their effectiveness in reducing morbidity.Cost-effectiveness analyses on educational interventions suggest that reductions in direct costs are most prominently seen for severe asthma, with the interpretation of study findings impaired by a lack of methodological consistency. One analysis from a study that included physical interventions found that the incremental cost-effectiveness ratio was $US9.20 per symptom-free day (95% CI-$US12.56, $US55.29), with potential cost savings for more severe asthma.We point out that current practice in managed care organizations (MCOs), as well as in other settings, rarely conforms to the current clinical practice guidelines for asthma. Two reviews of the policies and actions of MCOs found that while some were integrating environmental controls into their asthma disease management plans, their commitment to these strategies was limited by lack of a strong evidence base. We recommend the following: (i) continuation of educational programs; (ii) continuation and expansion of case management, including home visits; (iii) full integration of smoking cessation programs into asthma disease management; (iv) development of policies around reimbursement for durable goods; (v) participation in the setting of a policy agenda for population-based approaches to controlling key environmental factors; (vi) development of exploratory programs to address occupational asthma; (vii) integration, analysis and dissemination of environmental data collected by MCOs; and (viii) widespread MCO participation in research on environmental prevention of asthma.

We quantified the air quality benefits of a smoke-free workplace law in Boston Massachusetts, U.S.A., by measuring air pollution from secondhand smoke (SHS) in 7 pubs before and after the law, comparing actual ventilation practices to engineering society (ASHRAE) recommendations, and assessing SHS levels using health and comfort indices.

The authors sought to determine levels of urinary cotinine and its association with collateral exposure to second-hand smoke in public health workers. Urinary cotinine was measured twice at 1-wk intervals in 28 public health workers or their spouses. Information on sources of second-hand smoke exposure and a dietary history were obtained from each participant. Geometric mean and median cotinine levels were 2.74 and 2.33 ng/mL, respectively. Only 6 instances of second-hand smoke exposure were reported from a combined 204 days of potential exposure, and these did not correspond to higher cotinine values. There was no association between consumption of foods containing nicotine and log-transformed urine cotinine levels (p = .80). The authors' analysis indicates dietary sources of nicotine are not important, even for persons with very low urinary cotinine levels. Further study is needed to determine sources of variation in urinary cotinine among largely unexposed populations.

Residents of Boston's Chinatown and the Vietnamese community in Boston's Dorchester section are recent immigrants from China and Vietnam, countries whose smoking prevalence rates for men are among the highest in the world and whose rates for women are very low. We conducted exploratory focus groups in these communities to examine issues related to secondhand smoke and to generate message concepts for health education materials that would convince recent Asian immigrants to respond to the public health threat that secondhand smoke poses. The message concepts, which were tailored specifically for Chinese and Vietnamese immigrants, used themes that were consistent with the cultural values of each group as expressed in the focus groups, yet also reflected the fact that, in many ways, these immigrants are seeking to adapt to American norms. We suggest that it is possible to construct culturally appropriate health education materials for recent immigrant populations rather than rely on simple translations of English-language materials. An intervention study using these message concepts is needed.