Smoking, standard of living, and poverty in China

Objectives: To analyse differences in smoking behaviour and smoking expenditures among low and high income households in China and the impact of smoking on standard of living of low income households in China. Methods: About 3400 urban and rural households from 36 townships/districts in southwest China were interviewed in 2002. Cross tabulations and regression analysis were used to examine the differences in major household expenditures, including food, housing, clothing, and education between households with smokers and without smokers. Results: Lower income households with smokers paid less per pack and smoked fewer cigarettes than higher income households with smokers. Poor urban households spent an average of 6.6% of their total expenditures on cigarettes; poor rural households spent 11.3% of their total expenditures on cigarettes. Conclusion: Reducing cigarette expenditures could release household resources to spend on food, housing, and other goods that improve living standards.     

Sociodemographic and psychosocial correlates of smoking-induced deprivation and its effect on quitting: findings from the International Tobacco Control Policy Evaluation Survey

Aims

To determine the prevalence and characteristics of smokers who experience smoking‐induced deprivation (SID), and to examine its effect on quit attempts, relapse and cessation.

Methods

Waves 2 and 3 (2003–5) of the International Tobacco Control Policy Evaluation Survey were used, which is a prospective study of a cohort of smokers in the US, Canada, UK and Australia. SID was measured with the question “In the last six months, have you spent money on cigarettes that you knew would be better spent on household essentials like food?” A total of 7802 smokers participated in the survey in wave 2, of whom 5408 were also interviewed in wave 3.

Findings

The proportion of smokers who reported SID was highest in Australia (33%) and lowest in the UK (20%). Younger age, minority status and low income were associated with a higher probability of SID. Some of the other factors related to a higher probability of SID were higher level of nicotine dependence, having an intention to quit, and smoking to help one socialise or control weight. The relationship between SID and quit attempt was mediated by having an intention to quit and worrying that smoking would damage health and reduce the quality of life. The relationship between SID and relapse was mediated by perceived stress. SID was not associated with successful cessation.

Conclusions

Many smokers experience deprivation that is the result of their smoking. Strategies to reduce the prevalence of smoking probably effect a general improvement in standards of living and reduction in deprivation.The relationship between socioeconomic status and smoking is well established, with lower socioeconomic groups having a markedly higher prevalence of smoking in developed and many developing countries.^1,2,3,4 In addition to the common measures of socioeconomic status such as education and occupation, smoking has also been associated with direct indicators of deprivation such as financial stress. Marsh and McKay''s⁵ study on low‐income British families found that smoking was a strong predictor of financial hardship (experiencing financial anxiety, being in debt and being unable to afford consumer items such as food and clothing), independently of a lack of educational qualifications, low income, manual work, claiming welfare benefits and social tenancy. Similarly, Siahpush et al⁶ found that in Australia, households reporting tobacco expenditure were more likely to experience financial stress (measured by indicators such as being unable to afford meals or heat the home owing to shortage of money), after controlling for several indicators of socioeconomic status and demographic factors. Finally, Efroymson et al⁷ reported that in Bangladesh, tobacco expenditure exacerbates the effects of poverty and causes substantial deterioration in living standards among the poor.In the general population, there is a relationship between socioeconomic status, deprivation and being a smoker, and also among smokers, between socioeconomic status, amount smoked and deprivation. Siahpush⁸ reported that in Australia, smoking households headed by people with lower education and occupation spent more money on tobacco. He also showed that households with lower income were more likely to spend a higher percentage of their total household income on tobacco. Furthermore, Siahpush et al⁶ found that, among smoking households, a higher percentage of total household expenditure on tobacco was associated with several indexes of financial stress.Several qualitative studies also document the connection between smoking and deprivation. Bancroft et al,⁹ in a study on smokers from two socially disadvantaged areas in Scotland, reported that smoking was closely associated with dealing with difficult and stressful aspects of daily lives, as well as with boredom due to a lack of alternative activities. Similarly, Copeland¹⁰ studied a group of women from an economically and socially disadvantaged area in northwest Edinburgh and found that the pivotal role of smoking in their lives was that of a coping mechanism, particularly in response to problems such as financial stress, divorce, bereavement and worries about children. Finally, Stead et al''s¹¹ research undertaken in disadvantaged communities in Glasgow suggested that lack of resources, a stressful environment, strong pro‐smoking community norms and limited opportunities for recreation seem to foster smoking and discourage cessation.The correlational and qualitative studies cited above provide only partial evidence that smoking results in deprivation. We know of no previous studies that use indicators of smoking‐induced deprivation (SID) such as a smoker''s direct report about spending money on cigarettes that should otherwise have been spent on essentials such as food. The International Tobacco Control Policy Evaluation Survey (ITCPES) provides such an indicator. Our aim was to determine the extent to which smokers experience SID, to investigate the sociodemographic and psychosocial characteristics of smokers who experience SID and to examine its effect on quit attempts, relapse and cessation, in the US, Canada, UK and Australia by using this indicator.     

Female-headed households and food insecurity in Brazil

The National Household Survey carried out in 2009 by Brazil??s bureau of the census contains information on a representative sample of 121,708 households. The questionnaire includes items that enable us to identify households that experience moderate and severe degrees of food insecurity. The results of logistic regression analyses support the hypothesis that the odds of food insecurity are higher among female-headed households compared to male-headed households. Net of statistical controls for region, urban residence, age, monthly per capita household income, and five indicators of the internal composition of the household, the odds of moderate and severe food insecurity are, respectively, 32?% and 16?% higher among households headed by women compared to households headed by men. Further analyses show that the likelihood of food insecurity increases with presence of young children 0?C10?years of age and older children 11?C18?years of age. The importance of intra-household characteristics is confirmed by results that show that the odds of both moderate and severe food insecurity increase with additional adult males but decrease with additional adult females. Evidence that the presence of adult females reduces food insecurity is consistent with studies of gender differences in household decision making which show that, compared to men, women??s spending patterns have a greater positive effect on the welfare of children and other members of the household. The conclusions are discussed in the context of the poverty and hunger alleviation initiatives in Brazil??s new social policy agenda.     

Households contaminated by environmental tobacco smoke: sources of infant exposures

Objectives: To examine (1) whether dust and surfaces in households of smokers are contaminated with environmental tobacco smoke (ETS); (2) whether smoking parents can protect their infants by smoking outside and away from the infant; and (3) whether contaminated dust, surfaces, and air contribute to ETS exposure in infants.

Design: Quasi-experiment comparing three types of households with infants: (1) non-smokers who believe they have protected their children from ETS; (2) smokers who believe they have protected their children from ETS; (3) smokers who expose their children to ETS.

Setting: Homes of smokers and non-smokers.

Participants: Smoking and non-smoking mothers and their infants 1 year.

Main outcome measures: ETS contamination as measured by nicotine in household dust, indoor air, and household surfaces. ETS exposure as measured by cotinine levels in infant urine.

Results: ETS contamination and ETS exposure were 5–7 times higher in households of smokers trying to protect their infants by smoking outdoors than in households of non-smokers. ETS contamination and exposure were 3–8 times higher in households of smokers who exposed their infants to ETS by smoking indoors than in households of smokers trying to protect their children by smoking outdoors.

Conclusions: Dust and surfaces in homes of smokers are contaminated with ETS. Infants of smokers are at risk of ETS exposure in their homes through dust, surfaces, and air. Smoking outside the home and away from the infant reduces but does not completely protect a smoker's home from ETS contamination and a smoker's infant from ETS exposure.

     

Does consumption of tobacco and alcohol affect household food security? Evidence from rural India

Using a nationally representative household-level dataset on consumption expenditure, this paper examines the crowding-out effects of tobacco and alcohol spending on food and non-food consumption in rural India. We found a positive relationship between spending on these temptation goods and household income, but in proportionate terms the poor and socially-disadvantaged households spent more on such goods compared to others. In general, their consumption crowded out food expenditure but not as much as non-food expenditure. Tobacco expenditure crowded out more of consumer durables followed by foodgrains, healthcare and education. However, among the poor, foodgrains were traded-off more. Likewise, spending on alcohol also crowded out foodgrains, but the effects were larger for consumer durables and starker among the poor. Across social groups too, consumption of tobacco as well as alcohol led to a reallocation of budgets with consumer durables being most displaced followed by foodgrains. On the whole, the crowding out effects were larger for tobacco than alcohol and were greater for households belonging to the lower rungs of both income and social order. We identified that such crowding-out effects operated through peer effects or social interactions; hence the key inference is that government interventions aimed towards controlling tobacco or alcohol consumption would be more effective if these targeted peer groups and their group leaders.     

Food security in a remittance based economy

We interviewed 395 subsistence farming households from Chitwan, Nepal in order to identify the impact of remittances and other explanatory variables on child, adult, and household food security. The highest category of the IV - ordered probit regression models with cluster robust standard errors indicated that the food security status of households, adults and children was explained by gender and age of household head, adoption of conservation agricultural technology, number of fruit trees, and income from agricultural and livestock sources. Additional variables affecting only children’s food security were the adoption of hybrid rice or maize varieties and the wage income or salary earned within the district, whereas an additional variable affecting only household and adult food security was the wage income earned outside the district. Households receiving international remittances were more food secure than those households that did not receive such remittances.     

Hungry for tobacco: an analysis of the economic impact of tobacco consumption on the poor in Bangladesh

OBJECTIVE: To investigate the extent of tobacco expenditures in Bangladesh and to compare those costs with potential investment in food and other essential items. DESIGN: Review of available statistics and calculations based thereon. RESULTS: Expenditure on tobacco, particularly cigarettes, represents a major burden for impoverished Bangladeshis. The poorest (household income of less than $24/month) are twice as likely to smoke as the wealthiest (household income of more than $118/month). Average male cigarette smokers spend more than twice as much on cigarettes as per capita expenditure on clothing, housing, health and education combined. The typical poor smoker could easily add over 500 calories to the diet of one or two children with his or her daily tobacco expenditure. An estimated 10.5 million people currently malnourished could have an adequate diet if money on tobacco were spent on food instead. The lives of 350 children could be saved each day. CONCLUSION: Tobacco expenditures exacerbate the effects of poverty and cause significant deterioration in living standards among the poor. This aspect of tobacco use has been largely neglected by those working in poverty and tobacco control. Strong tobacco control measures could have immediate impact on the health of the poor by decreasing tobacco expenditures and thus significantly increasing the resources of the poor. Addressing the issue of tobacco and poverty together could make tobacco control a higher priority for poor countries.     

Smoking and financial stress

Aim: Stress relief is commonly provided as a reason for smoking. However, it is plausible that the cost of smoking may create financial stress, particularly among the poor. The aim of the study was to examine the relationship between smoking and financial stress.

Design: Cross sectional survey of households from private dwellings conducted by the Australian Bureau of Statistics (ABS), using a stratified multistage area sample design.

Setting: Australia, 1998–99.

Participants: Nationally representative sample of households (n = 6892).

Main outcome measures: The outcome measures of objective financial stress were two dichotomous variables indicating whether the household had experienced any financial stress or severe financial stress in the past 12 months.

Results: The odds of experiencing any financial stress were 1.5 (95% confidence interval (CI) 1.3 to 1.7) times greater, and the odds of severe financial stress were twice (95% CI 1.6 to 2.5) as large for smoking households than non-smoking households. The effect of smoking on financial stress did not vary significantly across categories of income. Among smoking households, higher percentage of total household expenditure on tobacco was significantly related to financial stress.

Conclusions: Given data were cross sectional, firm conclusions cannot be drawn about the causal relationship between smoking and financial stress. It is likely that they both affect each other. Undoubtedly, expenditure on tobacco will reduce available funds that could otherwise be used to ameliorate financial stress.

     

Targeting performance of three large-scale,nutrition-oriented social programs in Central America and Mexico

This study evaluated whether three nutrition-oriented programs in Central America and Mexico have been successful in targeting those households most vulnerable to undernutrition and poverty. For each country, nationally representative data sets were used to estimate cutoff points dividing the population into 10 equal-sized groups according to child anthropometric measurements (age-standardized height) and household income (per capita household expenditures). Households meeting eligibility criteria were then assessed using special baseline surveys or national data obtained before implementation of the program. Children in these households were classified according to national deciles of height-for-age, and households were classified according to expenditure deciles. In spite of markedly differing targeting strategies, each of the programs was well targeted, with 45% (Honduras and Mexico) and 52% (Nicaragua) of children in eligible households coming from the lowest two deciles of the national distributions, and virtually none from the upper two deciles. Similar results pertained to household income. These experiences demonstrate that vulnerable households can be targeted relatively straightforwardly, and that the need to do this does not in every case imply household-level income screening.     

Characteristics of low-level smokers.

Average daily cigarette consumption has decreased, and some evidence suggests that the rate of "some day" smoking has increased; however, relatively little is known about low-level smokers. The present analysis describes and compares low-level versus heavier smokers, using cross-sectional and longitudinal data. Data from the Community Intervention Trial for Smoking Cessation (COMMIT) were used in this analysis. Population-based cross-sectional tobacco use telephone surveys were performed in 22 North American communities in 1988 and 1993, and the prevalence and characteristics of low-level smoking and reasons for quitting are reported from the 1993 prevalence survey. In addition, a cohort of 6,603 smokers was identified in 1988 and interviewed again in 1993 and 2001 to assess patterns of low-level smoking over time and its association with smoking cessation. In 1988, 7.6% were low-level smokers; in 1993, 10.7% were low-level smokers. Compared with heavier smokers, low-level smokers were more likely to be female, older, not married, Black or Hispanic; to have a 4-year college degree; to have no other adult smokers in the household; and to wait longer in the day to have their first cigarette. Low-level smokers also were less likely to report trying to quit because of the expense of smoking or physician advice to quit. They were more likely to try to quit because of trying to set a good example; concern for second-hand smoke; and factors such as bad breath, smell, or the taste of smoking. Those who smoked full-priced premium brands and who worked in a completely smoke-free worksite were more likely to be low-level smokers. Compared with heavier smokers, low-level smokers had similar rates of making a future quit attempt, lower use rates of nicotine replacement therapy, and higher cessation rates. Low-level smokers may be a growing segment of the smoker population and have different characteristics, health risks, and intervention needs compared with their heavier smoking counterparts.     

Cigarette smoking patterns among young adults aged 18-24 years in the United States.

Most tobacco control programs focus on prevention for children or cessation for adults. Little is known about cigarette smoking among young adults. This study examined sociodemographic variables associated with current, daily, heavy, and light smoking among young adults in the United States. Data from the 1998-1999 Tobacco Use Supplement to the Current Population Survey (TUS-CPS) were used to examine cigarette smoking patterns and correlates of smoking among 15,371 young adults aged 18-24 years. We found that 26% of young adults were current smokers, 20% were daily smokers, and 8% were former smokers. Current smoking rates were higher among American Indians/Alaska Natives (33%) and Whites (31%) than among other racial/ethnic groups. Compared with white-collar workers, blue-collar and service workers were more likely to report current and daily smoking. Blue-collar workers also were more likely to report heavy smoking (OR = 1.97). The unemployed (those in the labor force but not currently working) and those reporting an annual household income of less than US$20,000 were more likely to report current, daily, and heavy smoking, compared with those not in the labor force and those reporting an annual household income of $20,000 or more, respectively. Young adults not currently enrolled in school were more than twice as likely to report current (OR = 2.36) and daily (OR = 2.90) smoking, compared with those currently enrolled in school. Differential cigarette smoking patterns by race/ethnicity, occupation, employment status, household income, and school enrollment status should be considered when developing interventions to reduce smoking among young adults.     

Does adopting legume-based cropping practices improve the food security of small-scale farm households? Panel survey evidence from Zambia

This study provides empirical evidence on whether and how integrating legumes into production systems affects measures of small-scale farm households’ food availability and access. We used nationally representative household panel survey data from Zambia to estimate the differential effects on cereal-growing households of incorporating grain legumes into their farms via cereal-legume intercropping, cereal-legume rotation, and other means (such as legume monocropping). Specifically, we tested the hypotheses that with all else equal, cereal-growing small-scale farm households that integrate grain legumes into their production systems have: (1) more availability of food as measured by total production of calories and protein; (2) more income from crop production or sales; and (3) increased food access. Results suggest that cereal-legume rotation was associated with statistically significant increases in production of calories and protein by a household as well as their gross value of crop sales; it may also improve their food access. In contrast, we found little evidence of statistically significant effects of cereal-legume intercropping and other forms of legume production on household food availability and access in Zambia.     

Maternal employment and income affect dietary calorie adequacy in households in Sri Lanka

Nutritional deficiencies among children and mothers in lower-income households in Sri Lanka continue to be a major obstacle to the country's social and economic development. This study investigates the factors affecting dietary caloric adequacy in Sri Lanka, paying special attention to maternal income. An econometric analysis was performed using a household data set collected from a sample of 183 low-income households in the urban, rural, and estate sectors. The results showed that on average, mothers and children in the sample did not consume adequate levels of calories according to the recommendations of the Medical Research Institute of Sri Lanka. The mother's income and educational status, the number of children and adults in the family, and the ages, sexes, and birth orders of the children significantly influenced household and individual caloric adequacy. Specifically, the mother's income had a significant positive effect on the total caloric intake (CI) and caloric adequacy ratio (CAR) of the household, mother, and children and a significant negative effect on the relative caloric allocation (RCA) of the children. The results imply that when maternal employment generates extra income, the CIs of all individuals increase, yet the allocation of calories to the children of the household is reduced. Thus, provision of employment opportunities for mothers, along with adequate child-care facilities and nutritional educational programs, is a possible strategy to improve caloric adequacy among low-income households in Sri Lanka.     

Trends in environmental tobacco smoke restrictions in the home in Victoria, Australia

OBJECTIVE: To assess the extent to which smokers and non-smokers in Victoria, Australia attempt to keep their homes smoke free and to determine whether the proportion of people attempting to do so has changed over time. DESIGN: Face to face surveys conducted in Victoria each year from 1989 to 1997. PARTICIPANTS: Approximately 2500 randomly selected adults each year. MAIN OUTCOME MEASURES: Proportion of respondents who discourage their visitors from smoking; proportion of smokers who always smoke outside their own homes; behaviour of smokers when they are around children. Changes in each of these measures over time. RESULTS: Reports of visitors being discouraged from smoking rose from 27% in 1989 to 53% in 1997. Smokers who reported always smoking outside the home rose from 20% in 1995 to 28% in 1997. Not smoking in the presence of children rose from 14% in 1989 to 33% in 1996. Indoor restrictions on smoking were associated with the presence of children in the household and even more strongly with the presence of non-smoking adults. People who worked in places where smoking was totally banned were more likely to ask their visitors not to smoke than those who worked where smoking was allowed. CONCLUSIONS: The results indicate a strong move towards homes and towards protecting children from smoke. Efforts to support and facilitate this social change should be further encouraged.     

Was there significant tax evasion after the 1999 50 cent per pack cigarette tax increase in California?

OBJECTIVES: Several states, including California, have implemented large cigarette excise tax increases, which may encourage smokers to purchase their cigarettes in other lower taxed states, or from other lower or non-taxed sources. Such tax evasion thwarts tobacco control objectives and may cost the state substantial tax revenues. Thus, this study investigates the extent of tax evasion in the 6-12 months after the implementation of California's 0.50 dollars/pack excise tax increase. DESIGN AND SETTING: Retrospective data analysis from the 1999 California Tobacco Surveys (CTS), a random digit dialled telephone survey of California households. MAIN OUTCOME MEASURES: Sources of cigarettes, average daily cigarette consumption, and reported price paid. RESULTS: Very few (5.1 (0.7)% (+/-95% confidence limits)) of California smokers avoided the excise tax by usually purchasing cigarettes from non- or lower taxed sources, such as out-of-state outlets, military commissaries, or the internet. The vast majority of smokers purchased their cigarettes from the most convenient and expensive sources: convenience stores/gas (petrol) stations (45.0 (1.9)%), liquor/drug stores (16.4 (1.6)%), and supermarkets (8.8 (1.2)%). CONCLUSIONS: Despite the potential savings, tax evasion by individual smokers does not appear to pose a serious threat to California's excise tax revenues or its tobacco control objectives.     

Tobacco use in six economically disadvantaged communities in the Dominican Republic.

The Dominican Republic is a tobacco-growing country, and tobacco control efforts there have been virtually nonexistent. This study provides a first systematic surveillance of tobacco use in six economically disadvantaged Dominican Republic communities (two small urban, two peri-urban, two rural; half were tobacco growing). Approximately 175 households were randomly selected in each community (total N = 1,048), and an adult household member reported on household demographics and resources (e.g., electricity), tobacco use and health conditions of household members, and household policies on tobacco use. Poverty and unemployment were high in all communities, and significant gaps in access to basic resources such as electricity, running water, telephones/cell phones, and secondary education were present. Exposure to tobacco smoke was high, with 38.4% of households reporting at least one tobacco user, and 75.5% allowing smoking in the home. Overall, 22.5% reported using tobacco, with commercial cigarettes (58.0%) or self-rolled cigarettes (20.1%) the most commonly used types. Considerable variability in prevalence and type of use was found across communities. Overall, tobacco use was higher in males, illiterate groups, those aged 45 or older, rural dwellers, and tobacco-growing communities. Based on reported health conditions, tobacco attributable risks, and World Health Organization mortality data, it is estimated that at least 2,254 lives could potentially be saved each year in the Dominican Republic with tobacco cessation. Although it is expected that the reported prevalence of tobacco use and health conditions represent underestimates, these figures provide a starting point for understanding tobacco use and its prevalence in the Dominican Republic.     

Cost-effectiveness of a targeted disinfection program in household kitchens to prevent foodborne illnesses in the United States, Canada, and the United Kingdom

Foodborne illnesses impose a substantial economic and quality-of-life burden on society by way of acute morbidity and chronic sequelae. We developed an economic model to evaluate the potential cost-effectiveness of a disinfection program that targets high-risk food preparation activities in household kitchens. For the United States, Canada, and the United Kingdom, we used published literature and expert opinion to estimate the cost of the program (excluding the educational component); the number of cases of Salmonella, Campylobacter, and Escherichia coli O157:H7 infections prevented; and the economic and quality-of-life outcomes. In our primary analysis, the model estimated that approximately 80,000 infections could be prevented annually in U.S. households, resulting in 138 million dollars in direct medical cost savings (e.g., physician office visits and hospitalizations avoided), 15,845 quality-adjusted life-years (QALYs) gained, 788 million dollars in program costs, and a favorable cost-effectiveness ratio of 41,021 dollars/QALY gained. Results were similar for households in Canada and the United Kingdom (21,950 dollars Can/QALY gained and 86,341 pounds sterling/QALY gained, respectively). When we evaluated implementing the program only in U.S. households with high-risk members (those less than 5 years of age, greater than 65 years of age, or immunocompromised), the cost-effectiveness ratio was more favorable (10,163 dollars/QALY gained). Results were similar for high-risk households in Canada and the United Kingdom (1,915 dollars Can/QALY gained and 28,158 pounds sterling/QALY gained, respectively). Implementing a targeted disinfection program in household kitchens in the United States, Canada, and the United Kingdom appears to be a cost-effective strategy, falling within the range generally considered to warrant adoption and diffusion (<100,000 dollars/QALY gained).     

Quantifying carbon footprint reduction opportunities for U.S. households and communities

Carbon management is of increasing interest to individuals, households, and communities. In order to effectively assess and manage their climate impacts, individuals need information on the financial and greenhouse gas benefits of effective mitigation opportunities. We use consumption-based life cycle accounting techniques to quantify the carbon footprints of typical U.S. households in 28 cities for 6 household sizes and 12 income brackets. The model includes emissions embodied in transportation, energy, water, waste, food, goods, and services. We further quantify greenhouse gas and financial savings from 13 potential mitigation actions across all household types. The model suggests that the size and composition of carbon footprints vary dramatically between geographic regions and within regions based on basic demographic characteristics. Despite these differences, large cash-positive carbon footprint reductions are evident across all household types and locations; however, realizing this potential may require tailoring policies and programs to different population segments with very different carbon footprint profiles. The results of this model have been incorporated into an open access online carbon footprint management tool designed to enable behavior change at the household level through personalized feedback.     

Accuracy of parental reporting of secondhand smoke exposure: The National Health and Nutrition Examination Survey III.

The accuracy of parental reports of youth secondhand smoke exposure has received limited attention in the research literature. Such reports were compared to serum cotinine levels among participants of the National Health and Nutrition Examination Survey III who were aged 4-16 years. Likely smokers with serum cotinine values of 14 ng/ml or more and self-reported tobacco users were excluded from the analysis (n = 87), leaving 2,524 youth participants. One adult guardian, typically the parent, was asked to identify household smokers and estimate the number of cigarettes smoked in the home. Using cotinine levels of at least 0.2 ng/ml as the criterion, we found the sensitivity and specificity of any reported smokers in the home to be .65 and .92, respectively. Spearman correlations between cotinine levels and the number of smokers and the number of cigarettes consumed in the household were .67 and .68, respectively, and varied little across subgroups, including age, gender, and ethnicity of the child as well as household poverty status and educational attainment of the parent. Parental reports of household smoking alone fail to capture all youth secondhand smoke exposures, but they correlate well with cotinine levels when expressed as the number of household smokers or the number of cigarettes smoked in the household. Additional research is needed to determine whether reliance on parental reports of secondhand smoke exposure leads to bias in studies examining health outcomes in children and adolescents. Also, additional research is needed to better determine the level of secondhand smoke exposure that is biologically important in children and adolescents.