Steven is 13 years old and in the sixth grade. He is tall and thin, slightly pale in appearance. He comes from a large family, living in a small mobile home with his parents, siblings, and niece. His father is a truck driver, his mom a secretary. His sister is 17 and works part-time while caring for her 2-year-old daughter and preparing for the GED.
Steven's 15-year-old brother is away in a juvenile detention “boot camp” after being caught attempting to sell marijuana. His youngest brother is 8 and doing well in school. Two months ago, his parents moved his grandmother in to the already-crowded home to care for her after she fractured her hip.
Steven attends public school. He often appears distracted and generally stands out in his classes for lack of facility of learning. Today, during math class, Steven rested with his head down on the desk. His teacher called him to the blackboard to work a problem. Murmuring that he didn't feel well, Steven took a few steps and started coughing and wheezing before reaching the blackboard. The school nurse was called in, and his parents were called immediately. Steven is sent to the nurse's office to rest.
During recess, the nurse and principal met briefly with each of Steven's instructors to find out what may have caused Steven's breathing problems. Each teacher relayed a similar story. During the previous 3 to 4 weeks, Steven has had episodes of moodiness and has been quite listless at times. He has constantly requested going to the nurse's office with a variety of medical complaints: sometimes dizziness, a headache, chest pain, irritated eyes, earache, shortness of breath, or upset stomach. With his history of learning and behavioral problems, his instructors rarely took him seriously. It was thought that he was embarrassed by his school and behavior problems and wanted out of the classroom.
His family history and behavior caused the nurse to suspect a drug problem. Before his parents arrived, she asked Steven if he had ever experimented with alcohol or drugs. As Steven began to respond, he had a terrible coughing fit. The nurse brought him a cup of water. When he regained his composure, Steven denied substance abuse of any kind. The nurse asked how long he's had such a bad cough and if he is taking any medication. He told her he has had the cough for 2 to 3 weeks but is not taking anything. The nurse asked about his family; no one else is ill or on medication.
Steven explained that he woke up feeling fine, but after his first class, he felt dizzy and nauseated, with an earache and sore throat. Because he skipped breakfast, he thought that if he could just rest awhile during math class, he would be fine. However, his teacher called him to the board, and he said when he stood up, he felt even dizzier and was about to ask his instructor to be excused when the coughing and wheezing began.
At that point, the principal entered with Steven's parents. Steven's father smelled strongly of smoke. The nurse and principal explain Steven's behavior and list of physical problems. The nurse suggested Steven be evaluated for his behavior and refers Steven to a pediatrician for the physical symptoms, requesting he be kept at home until he gets better.
The following week, Steven and his parents are able to see the doctor and explain the events leading up to the visit. Steven's mom mentions her 8-year-old complains that Steven has started to snore a lot lately. Steven is soon diagnosed with an ear infection secondary to pneumonia. However, the story of Steven's mood and behavior prompts the doctor to refer Steven to an addiction specialist in the same office. Steven's parents are cooperative but have no idea what may have caused his problems with learning, his behavior and his physical problems.
The family is in fairly good health, with no parental history of alcohol or illicit drug abuse. The specialist requests blood, urine, and saliva tests to see if Steven's admitted abstinence from drugs holds true. Due to the severity of Steven's physical illness, the specialist also requests tests for cotinine, a nicotine metabolite. Days later, after conferring with the pediatrician, the specialist asks Steven's parents to come back and discuss the test results.
The specialist asks if either of the parents smoke. Steven's mother responds that she smokes occasionally, maybe six cigarettes a day. Steven's father; eager to know the outcome of all the tests, is angered by the question, asking why his personal habits are relevant. Steven's mother goes on to say that her husband's occupation keeps him away from home during the day, and he only smokes half a pack of cigarettes a day, either before or after work. He usually smokes outside on the porch, but does walk in and out to watch television and talk. He has smoked for at least 20 years.
Steven's mother also mentions that her mother-in-law recently moved in, and Steven adores her, spending most of his time sitting with her and helping out when needed. Steven's grandmother smokes a pack of cigarettes a day. No one else in the household smokes.
Steven's mother asks why their smoking habits are relevant. The specialist responds that most of Steven's drug tests came back negative; however, he had elevated levels of cotinine in his serum and urine.
These options could be considered as appropriate management strategies for the clinician:
Refer Steven to treatment for nicotine dependence.
Start Steven on medication for respiratory distress.
Have all members of the household, and all guests, refrain from smoking indoors.
Ask Steven's parents and grandmother to consider quitting smoking and refer them to smoking cessation therapy if possible.
In this case, Option 3 was chosen, as it is most feasible and can be implemented immediately. According to the 1990 Surgeon General's report on The Health Benefits of Smoking Cessation, the general consensus suggests a dose-response relationship of secondhand smoke and its implicated adverse events.1 Remove the harmful agent, and Steven's health status should improve. Taking action to make Steven's home smoke-free may spur his parents and grandmother to consider quitting, which will in turn improve the health of the entire family.
Quitting smoking confers immediate health benefits and reduces risk of morbidity (eg, cancer, heart disease, lung disease) and mortality.1 If these changes occur in the lives of the smoker, at minimum, we expect improvements in the health of passive smokers who were previously exposed to their smoke.
Steven also will receive treatment for his pneumonia and ear infection from his pediatrician, and nicotine dependence treatment may be considered later if necessary.
This case presents some typical symptoms of early secondhand smoke exposure. Secondhand smoke is a known indoor air pollutant, containing more than 4,800 chemical compounds, at least 60 of which are known carcinogens. It is associated with the exacerbation of asthma and other respiratory infections; it may cause buildup of fluid in the middle ear, and may lead to sudden infant death syndrome (SIDS).2 Secondhand smoke is composed of side-stream smoke given off of the burning end of a cigarette — including cigars, pipes, bidis, kreteks, and cloves — and mainstream smoke exhaled by the smoker.3
Nicotine's metabolite, cotinine, is detected readily in urine, serum, and saliva. As early as 1984, Matsukura et al.4 found urinary cotinine levels of nonsmokers living with smokers were higher than those of non-smokers who lived only with other nonsmokers. The cotinine levels increased with the combined daily cigarette consumption of smokers in the household.
Every day, 21% of middle school youth and 26% of high school youth are exposed to secondhand smoke at home or in another building. At least once a week, 63% of all children and adolscents are exposed to secondhand smoke.5 According to the Roy Castle Lung Cancer Foundation, secondhand smoke affects the cardiovascular system and is linked to chest pain in children.6 The Action on Smoking and Health public health charity states that the immediate effects of secondhand smoke include “eye irritation, headache, cough, sore throat, dizziness and nausea.”7 Gaynor et al.8 found secondhand smoke exposure among students in fourth through seventh grades is associated with self-reported earaches.
In addition to the physical implications of secondhand smoke, there are proven mental effects, especially among children. Using data from the Third National Health and Nutrition Examination Survey, Yolton et al.9 showed cognitive deficits among 6- to 16-year-olds, even at the lowest levels of exposure to secondhand smoke. Serum cotinine levels were higher among blacks, families with lower household income or educational achievement, those living in the Midwest, and those with high blood lead concentrations.
Editor's Note: This monthly presentation describes a case of a psychiatric disorder, discusses past treatment attempts, offers options for continuing treatment, and explains the reasons the solution was selected. Submissions of interesting psychiatric case reports are now being accepted for this department. Please e-mail
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This case is presented by Mark S. Gold, MD, distinguished professor, McKnight Brain Institute, Departments of Psychiatry, Neuroscience, Anesthesiology, Community Health & Family Medicine, and chief, Division of Addiction Medicine, University of Florida, Gainesville, FL; and Noni A. Graham, MPH, research coordinator, Department of Psychiatry, Division of Addiction Medicine, University of Florida.
- The Health Benefits of Smoking Cessation: A Report of the Surgeon General. US Department of Health and Human Services, US Public Health Service, Centers for Disease Control, Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. 1990. DHHS Publication No. (CDC) 90-8416. Available at http://profiles.nlm.nih.gov/NN/B/B/C/T/_/nnbbct.pdf. Accessed May 20, 2005.
- Smoking 101 Fact Sheet. American Lung Association. 2004. Available at: http://www.lungusa.org/site/apps/s/content.asp?c=dvLUK9O0E&b=34706&ct=66713. Accessed May 25, 2005.
- Secondhand Smoke Fact Sheet. Tobacco Information and Prevention Source (TIPS)Centers for Disease Control and Prevention. February2004. Available at http://www.cdc.gov/tobacco/factsheets/secondhand_smoke_factsheet.htm. Accessed May 25, 2005.
- Matsukura S, Taminato T, Kitano N, et al. Effects of environmental tobacco smoke on urinary cotinine excretion in non-smokers. Evidence for passive smoking. N Engl J Med. 1984;311(13):828–832. doi:10.1056/NEJM198409273111305 [CrossRef]6472384
- Secondhand Smoke. American Legacy Foundation. March 28, 2003. Available at http://www.kstask.org/pdf/factsheets/Secondhand%20Smoke.pdf. Accessed May 25, 2005.
- Health risks of exposure to secondhand smoking – children. The Roy Castle Lung Cancer Foundation: The National Clean Air Award. 2004. Available at http://www.cleanairaward.org.uk/info_secondc.htm. Accessed May 25, 2005.
- Secondhand smoke. Action on Smoking and Health. 2005. Available at: http://www.ash.org.uk/html/factsheets/html/fact08.html. Accessed May 25, 2005.
- Gaynor J, Trapido E, Lee D. Secondhand smoke and earaches in adolescents: the Florida Youth Cohort Study. Nicotine Tob Res. 2003;5(6):943–946 doi:10.1080/14622200310001615803 [CrossRef]14668078
- Yolton K, Dietrich K, Auinger P, Lanphear BP, Hornung R. Exposure to environmental tobacco smoke and cognitive abilities among US children and adolescents. Environ Health Perspect. 2005;113(1):98–103. doi:10.1289/ehp.7210 [CrossRef]15626655