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Journal of Pediatric Psychology logoLink to Journal of Pediatric Psychology
. 2020 Dec 22;46(4):454–464. doi: 10.1093/jpepsy/jsaa123

Exposure to Tobacco Smoke and Temperament among U.S. Children 0–5 Years Old

Ashley L Merianos 1,✉, Laura A Nabors 1, Kayleigh A Fiser 1, E Melinda Mahabee-Gittens 2
PMCID: PMC8056209  PMID: 33355348

Abstract

Objectives

This study examined the association between tobacco smoke exposure (TSE) and temperament among children 0–5 years old overall and within age groups: 0–2 and 3–5 years.

Methods

Data were obtained from the 2017–2018 NSCH (N = 14,345). TSE status was defined as whether children lived with a smoker who: does not smoke inside the home (no home TSE) or smokes inside the home (home TSE). We conducted logistic regression analyses while controlling for covariates.

Results

Overall, 12.5% of children lived with a smoker with no home TSE and 1.1% had home TSE. Children with home TSE were at increased odds to not always: be affectionate and tender (aOR = 1.74, 95% CI = 1.18–2.58), show interest and curiosity (aOR = 1.81, 95% CI = 1.23–2.68), and smile and laugh (aOR = 1.77, 95% CI = 1.13–2.77) than those with no TSE. Among 0- to 2-year-olds, those with home TSE were more likely to not always be affectionate and tender (aOR = 1.97, 95% CI = 1.04–3.74). Among 3- to 5-year-olds, those who lived with a smoker with no home TSE were more likely to not always: bounce back quickly (aOR = 1.21, 95% CI = 1.05–1.40) and smile and laugh (aOR = 1.26, 95% CI = 1.03–1.54), and those with home TSE were more likely to not always: show interest and curiosity (aOR = 2.24, 95% CI = 1.40–3.59) and smile and laugh (aOR = 2.43, 95% CI = 1.43–4.11).

Conclusions

Tobacco smoke-exposed children were at increased odds of not always demonstrating positive early childhood temperament behaviors, with 3- to 5-year-olds having more pronounced odds.

Keywords: health disparities and inequities, mental health, public health, tobacco use

Introduction

Although adult cigarette smoking is at a historical low (Creamer et al., 2019), 35% of children are exposed to tobacco smoke in the United States. (Brody et al., 2019). Rates of exposure are even higher (up to 64%) in low-income populations of infants and toddlers (Gatzke-Kopp et al., 2019). Tobacco smoke exposure (TSE), defined as secondhand and thirdhand smoke, is one of the most frequent pollutants children are exposed to indoors. Although secondhand smoke is the temporary inhalation of smoke from a lit cigarette, thirdhand smoke is aged secondhand smoke that persists in indoor environments long after smoking has ceased (Jacob et al., 2017). Prior research using the 2007 National Survey of Children’s Health (NSCH) found that children exposed to tobacco smoke in the home are at 50% increased risk of having at least two childhood neurobehavioral disorders (e.g., attention-deficit/hyperactivity disorder, learning disability), and that males, those with low income, and older children were at increased odds (Kabir et al., 2011). Children of maternal smokers have a lower likelihood of meeting age-specific developmental milestones and may experience developmental delays (Slykerman et al., 2007). While it is known that exposure to secondhand smoke increases the risk of neurobehavioral health issues in children (U.S. Department of Health and Human Services, 2014), developing evidence indicates exposure to thirdhand smoke may be associated with similar health effects (Jacob et al., 2017). Thus, it is important to consider TSE in terms of exposure to secondhand and thirdhand smoke in the homes of smokers who smoke inside the home, and also exposure to thirdhand smoke in the homes of smokers who do not smoke inside the home.

Temperament is a multidimensional indicator of neurobehavioral development with behavioral characteristics that often manifest as emerging individual differences during the early childhood developmental periods of infancy, toddlerhood, and the preschool years (Buss & Plomin, 1975; Rothbart & Bates, 2006; Thomas & Chess, 1977). Temperament theories share common dimensions including emotion, self-regulation, and activity level. This study focused on Rothbart’s psychobiological theoretical model that was originally developed to describe temperament during infancy (Rothbart, 1981; Rothbart & Ahadi, 1994), and was expanded to include other developmental periods including toddlerhood (Putnam et al., 2006) and the preschool years (Rothbart et al., 2001). This theory includes three broad temperament dimensions: effortful control (e.g., interest and curiosity in learning new things), negative affectivity (e.g., responses when things do not go one’s way), and extraversion/surgency (e.g., smiling and laughter, affectionate and tender). Research in support of evaluating such domains as constructs of early childhood temperament indicate that these characteristics generally remain moderately stable during the infant (Carranza Carnicero et al., 2000), toddler and preschool developmental years (Kagan et al., 1984). For example, infant smiling and laughter are measures of temperament that remain constant over time (Carranza Carnicero et al., 2000). Consequently, suboptimal neurobehavioral development during toddlerhood may lead to reduced educational attainment and cognitive outcomes well into adulthood (Murray et al., 2007). Since the development of certain temperament characteristics may be observed during different times in early childhood (Rothbart & Bates, 2006), it is important to assess these early childhood years in their entirety, and by developmental age group.

Preliminary evidence indicates that socio-environmental factors may influence temperament development starting in infancy (Beekman et al., 2015). A substantial body of evidence has demonstrated the effects of maternal smoking during pregnancy on negative neurobehavioral health outcomes (Micalizzi & Knopik, 2018; Rogers, 2009; U.S. Department of Health and Human Services, 2014). Postnatal TSE is associated with a risk of neurodevelopmental delays, but there is a gap in the epidemiological literature that focuses on child TSE and temperament measures during the developmental periods of infancy and toddlerhood (0–2 years) to preschool years (3–5 years; Chen et al., 2013). Further, research shows a negative association between child age and biochemically validated TSE with the highest TSE levels noted during infancy and toddlerhood compared with the preschool age period and beyond (Gatzke-Kopp et al., 2019; Mahabee-Gittens et al., 2019), highlighting the importance of assessing early childhood overall, and by age groups.

The objective was to examine the association between TSE and early childhood temperament among U.S. children 0–5 years old overall, and within two developmental age groups: 0–2 and 3–5 years. TSE is defined as children who: do not live with a smoker (no TSE), live with a smoker who does not smoke inside the home (no home TSE), and live with a smoker who smokes inside the home (home TSE). When compared with children with no TSE, we posited that children who lived with a smoker with no home TSE and who lived with a smoker with home TSE would be less likely to have parent-reported ratings of favorable temperament.

Materials and Methods

Participants and Procedures

Data were obtained from the 2017–2018 NSCH, which is conducted by the U.S. Census Bureau with direction and funding from the U.S. Maternal and Child Health Bureau (U.S. Census Bureau 2018, 2019). NSCH is a U.S.-based, cross-sectional survey that collects data on the health and healthcare needs of 0- to 17-year-old children. For specific details, please refer to the NSCH Methodology Reports (U.S. Census Bureau, 2018, 2019). In brief, NSCH randomly sampled and contacted households by mail, and invited adult household members to complete an internet- or paper-based short screener to identify all children in their household. In the initial invitation letter, 90% of households received a small cash incentive ($2–$5) to complete the survey. Adults who completed the Internet-based screener and lived with ≥1 child were immediately directed to one of three age-specific topical questionnaires (0–5, 6–11, or 12–17 years) for one randomly selected child as the subject. Respondents also had the option to request a paper-based version. The U.S. Census Bureau mailed up to five invitations in 2017, four invitations in 2018, and up to two reminder postcards in both years. The 2017–2018 NSCH oversampled 0- to 5-year-olds at 60% since this age range is commonly underrepresented in household surveys. The 2017 NSCH was conducted between August 2017 and February 2018 with a weighted overall response rate of 37.4% (N = 21,599; U.S. Census Bureau, 2018). The 2018 NSCH was conducted between June 2018 and January 2019 with a weighted overall response rate of 43.1% (N = 30,530) (U.S. Census Bureau, 2019).

Of the 52,129 children in 2017–2018 NSCH, we included 14,345 children age 0–5 years after excluding those who were >5 years old (n = 37,392) and missing data on TSE (n = 247) and child and family characteristics (i.e., child health status and family structure, n = 145). Significant differences in characteristics of 0- to 5-year-olds included (N = 14,345) versus excluded (n = 392) from this study were found based on child race, family structure, parent education level, and federal poverty level (FPL). A higher proportion of included children was non-Hispanic white, lived with two currently married parents, had parents with higher education, and had higher FPL. The institutional review board determined this study as “not human subjects” research due to the use of publicly available, de-identified NSCH data.

Measures

Child TSE

TSE was assessed by asking parents the following yes/no question, “Does anyone living in your household use cigarettes, cigars, or pipe tobacco?” If respondents answered “yes,” then they were asked the follow-up question, “If yes, does anyone smoke inside your home?” The responses to both questions were collapsed into one variable. TSE was defined as (a) no TSE: the child does not live with a smoker; (b) household smoker with no home TSE: the child lives with a smoker who does not smoke inside the home (i.e., thirdhand smoke exposure in the home); and (c) household smoker with home TSE: the child lives with a smoker who smokes inside the home (i.e., secondhand and thirdhand smoke exposure in the home).

Current Early Childhood Temperament

The “This Child’s Health” section was comprised of closed-ended questions including temperament measures. We included all four items that were asked about 0- to 5-year-olds’ current temperament with response options ranging from never to always. The four questions were: “How often…” (a) “Is this child affectionate and tender with you?,” (b) “Does this child bounce back quickly when things do not go his or her way?,” (c) “Does this child show interest and curiosity in learning new things?,” and (d) “Does this child smile and laugh?” Due to highly skewed responses with extremely low numbers observed in the never, sometimes, and usually responses, we collapsed groups into: always versus not always (i.e., never/sometimes/usually).

Child and Family Characteristics

We included the following covariates: child age (continuous), child sex, child race/ethnicity, child premature birth, child health status; parent education level; family structure and FPL. Child race/ethnicity included non-Hispanic white, non-Hispanic black, non-Hispanic other/multiracial, and Hispanic. Parents were asked a yes/no question about premature birth, “Was this child born more than 3 weeks before his or her due date?” (Child and Adolescent Health Measurement Initiative, 2019). If “yes”, then the child was considered being born premature. In the “This Child’s Health” section, parents were asked about the sampled child’s health status, “In general, how would you describe this child’s health?” Response options ranged from poor to excellent and were collapsed due to skewed responses into: excellent/very good and good/fair/poor. Parent education included the highest education level of the primary caregiver(s) living in the child’s household (≤high school graduate/equivalent, some college, and college degree). Family structure included: two parents who were currently married, two parents who were not currently married, single parent, and other family type including grandparents. FPL was computed by NSCH for public use to protect participants’ confidentiality using the ratio of total family income and family poverty thresholds for 2017–2018 that take into consideration family size and number of children <18 years old, and provided percentage categories based on State Children’s Health Insurance Program income qualification groups (U.S. Census Bureau, 2018, 2019): 0–199%, 200–299%, 300–399%, and ≥400%.

Data Analysis

We used a NSCH-provided sampling weight that accounts for combining two years of data and allows for generalizability of findings to national child resident populations and households with children. Specifically, a base weight was assigned to each sampled child case and then was adjusted for screener nonresponse, topical questionnaire nonresponse, the selection of one child from the sampled household, and to control the population counts for various child characteristics (U.S. Census Bureau, 2018, 2019). We computed descriptive statistics for all variables, and report raw sample size and weighted percent. We conducted a one-way analysis of variance test to examine the association between child age and TSE status, and chi-square tests to examine the associations between the categorical covariates and TSE status. First, we conducted four separate unadjusted logistic regression analyses to assess the associations between TSE status and each temperament outcome variable, and report odds ratios (ORs) and 95% CIs. Then, we built four multivariable regression models to assess these associations while adjusting for child age, child sex, child race/ethnicity, child premature birth, child health status, parent education level, family structure and FPL, and report adjusted ORs (aORs) and 95% CIs. To assess within group differences among 0- to 2- and 3- to 5-year-olds, we conducted similar unadjusted and adjusted regression analyses. Missing data were removed prior to each analysis. p-Values with < .05 were indicative of statistical significance.

Results

The overall mean child age was 2.7 (SD = 1.6) years and 48.8% were female (Table I). Over half (53.1%) were non-Hispanic white, 11.1% were non-Hispanic black, 12.1% were non-Hispanic other/multiracial, and 23.7% were Hispanic. About 12% of children were born prematurely and 7.2% had good/fair/poor health. Parent education, family structure and FPL varied as 54.1% of parents had a college degree or higher, 67.1% of children lived with two currently married parents, and 41.3% had a 0–199% FPL. Concerning TSE status, 12.5% of children (n = 1,736) lived with a household smoker with no home TSE and 1.1% (n = 131) lived with a household smoker with home TSE.

Table I.

Child and Family Characteristics of Children 0–5 Years Old by Tobacco Smoke Exposure Status, 2017–2018 NSCH

TSE status
Overall (N = 14,345) No TSE (n = 12,478) Household smoker no home TSE (n = 1,736) Household smoker home TSE (n = 131) p-Value
Characteristic n (%)a  n (%)a n (%)a n (%)a
Child age, M (SD) 2.7 (1.6) 2.7 (1.6) 2.8 (1.6)  3.1 (1.6) <.001
Child sex .38
 Male 7,420 (51.2) 6,466 (51.2) 894 (51.5) 60 (43.5)
 Female 6,925 (48.8) 6,012 (48.8) 842 (48.5) 71 (56.5)
Child race/ethnicity <.001
 Non-Hispanic white 9,901 (53.1) 8,588 (52.0) 1,232 (60.4) 81 (53.3)
 Non-Hispanic black 788 (11.1) 689 (11.3) 81 (8.3) 18 (25.1)
 Hispanic 1,669 (23.7) 1,479 (24.5) 181 (19.3) 9 (10.6)
 Non-Hispanic other/multiracial 1,987 (12.1) 1,722 (12.2) 242 (11.9) 23 (11.0)
Child premature birth <.001
 No 12,799 (88.4) 11,181 (88.4) 1,512 (88.6) 106 (83.7)
 Yes 1,440 (11.6) 1,208 (11.6) 211 (11.4) 21 (16.3)
Child health status .001
 Excellent/very good 13,575 (92.8) 11,839 (93.0) 1,618 (92.2) 118 (90.5)
 Good/fair/poor 770 (7.2) 639 (7.0) 118 (7.8) 13 (9.5)
Parent education level <.001
 <High school graduate/GED 1,810 (23.7) 1,281 (20.9) 475 (41.0) 54 (52.0)
 Some college 3,150 (22.2) 2,449 (21.1) 648 (28.6) 53 (33.5)
 College degree 9,385 (54.1) 8,748 (58.0) 613 (30.4) 24 (14.5)
Family structure <.001
 Two parents, currently married 10,689 (67.1) 9,749 (70.4) 895 (48.2) 45 (24.5)
 Two parents, not currently married 1,127 (9.9) 811 (8.6) 292 (17.4) 24 (26.1)
 Single parent 1,990 (16.7) 1,539 (15.3) 409 (25.3) 42 (26.4)
 Other family type 539 (6.3) 379 (5.7) 140 (9.1) 20 (23.0)
FPL <.001
 0–199% 4,017 (41.3) 3,137 (38.6) 786 (56.7) 94 (77.5)
 200–299% 2,347 (14.8) 2,017 (15.0) 314 (13.2) 16 (11.9)
 300–399% 2,177 (12.6) 1,920 (12.9) 247 (11.1) 10 (5.1)
 >400% FPL 5,804 (31.3) 5,404 (33.5) 389 (19.0) 11 (5.5)
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Note. NSCH, = National Survey on Children’s Health; TSE = tobacco smoke exposure.

a

n refers to raw scores and percentages are weighted column percent unless noted otherwise. Missing values excluded.

Child and Family Characteristics by TSE Status

All child and family characteristics significantly differed based on TSE status, with the exception of child sex (see Table I). Of those who lived with a household smoker with no home TSE, children had parents with education ≤high school (41.0%), lived with two unmarried parents (17.4%), and had 0–199% FPL (56.7%). Of those with home TSE, children had higher mean age of 3.1 (SD = 1.6) years, and were white (53.3%), black (25.1%), born prematurely (16.3%), had good/fair/poor health (9.5%), had parents with education ≤high school (52.0%), lived with two unmarried parents (26.1%), and had 0–199% FPL (77.5%).

TSE Status and Temperament among Children 0–5 Years Old

A total of 17.6% and 23.6% of children who lived with a smoker with no home TSE and with home TSE, respectively, were not always affectionate and tender with their parent (Table II). Nearly 40% and 32.6% of children who lived with a smoker with no home TSE and with home TSE, respectively, did not always bounce back quickly when things did not go their way. A total of 17.3% and 12.6% of children who lived with a smoker with no home TSE and 24.7% and 16.1% of children with home TSE were reported as not always: showing interest and curiosity in learning new things or smiling and laughing, respectively.

Table II.

Unadjusted Logistic Regression Model Results of the Association between Tobacco Smoke Exposure Status and Early Childhood Temperament among Children 0–5 Years Old, 2017–2018 NSCH

0–5 years old (N = 14,345)
 0–2 years old (n = 6,706)
 3–5 years old (n = 7,639)
Not always Univariate regression
 Not always Univariate regression
 Not always Univariate regression
TSE status n (%)a OR 95% CI p-Value n (%)a OR 95% CI p-Value n (%)a OR 95% CI p-Value
Child is affectionate and tender
 No TSE 2,433 (16.0) (Ref) (Ref) (Ref) 1,131 (15.5) (Ref) (Ref) (Ref) 1,302 (16.5) (Ref) (Ref) (Ref)
 Household smoker—no home TSE 379 (17.6) 1.15 1.02–1.30 .03 147 (17.3) 1.06 0.88–1.29 .55 232 (17.8) 1.21 1.03–1.42 .02
 Household smoker—home TSE 39 (23.6) 1.78 1.22–2.60 .003 15 (26.0) 2.04 1.10–3.80 .02 24 (21.9) 1.63 1.01–2.64 .04
Child bounces back quickly
 No TSE 4,740 (38.1) (Ref) (Ref) (Ref) 1,951 (32.7) (Ref) (Ref) (Ref) 2,789 (43.5) (Ref) (Ref) (Ref)
 Household smoker—no home TSE 713 (39.9) 1.14 1.03–1.26 .02 243 (28.1) 1.01 0.86–1.19 .93 470 (49.0) 1.19 1.04–1.36 .01
 Household smoker—home TSE 63 (32.6) 1.50 1.06–2.12 .02 20 (25.9) 1.50 0.84–2.68 .17 43 (37.0) 1.40 0.91–2.16 .13
Child shows interest and curiosity
  No TSE 2,147 (15.7) (Ref) (Ref) (Ref) 916 (14.6) (Ref) (Ref) (Ref) 1,231 (16.8) (Ref) (Ref) (Ref)
  Household smoker—no home TSE 355 (17.3) 1.23 1.09–1.40 .001 126 (15.2) 1.13 0.92–1.39 .23 229 (18.9) 1.28 1.09–1.50 .003
 Household smoker—home TSE 40 (24.7) 2.10 1.45–3.06 <.001 10 (21.2) 1.47 0.73–2.97 .28 30 (27.1) 2.39 1.52–3.75 <.001
Child smiles and laughs
 No TSE 1,659 (11.3) (Ref) (Ref) (Ref) 823 (12.2) (Ref) (Ref) (Ref) 836 (10.4) (Ref) (Ref) (Ref)
 Household smoker—no home TSE 244 (12.6) 1.06 0.92–1.23 .40 92 (10.8) 0.89 0.71–1.12 .32 152 (13.9) 1.22 1.01–1.47 .04
 Household smoker—home TSE 26 (16.1) 1.61 1.04–2.48 .03 6 (8.4) 0.90 0.38–2.14 .82 20 (21.1) 2.13 1.28–3.53 .004
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Note. NSCH = National Survey on Children’s Health; TSE = tobacco smoke exposure; OR = odds ratio; CI = confidence interval; Ref = reference group.

a

n refers to raw scores and percentages are weighted row percent. Missing values excluded.

Unadjusted model results indicated that when compared to children with no TSE, children who lived with a smoker with no home TSE and children who lived with a smoker with home TSE were more likely to not always: be affectionate and tender with their parent, bounce back quickly when things did not go their way, and show interest and curiosity in learning new things (see Table II). Children who lived with a smoker with home TSE were at increased odds to not always smile and laugh. Adjusted results indicated children who lived with a smoker with home TSE were at increased odds to not always be affectionate and tender with their parent (aOR = 1.74, 95%CI = 1.18–2.58) than children with no TSE, while controlling for child and family characteristics (Table III). Children who lived with a smoker with home TSE were 1.81 times more likely (95% CI = 1.23–2.68) to not always show interest and curiosity in learning new things and 1.77 times more likely (95% CI = 1.13–2.77) to not always smile and laugh.

Table III.

Multivariable Logistic Regression Model Results of the Association between Tobacco Smoke Exposure Status and Early Childhood Temperament among Children 0–5 Years Old, 2017–2018 NSCH

0–5 years old (N = 14,345)
 0–2 years old (n = 6,706)
 3–5 years old (n = 7,639)
Multivariable Regressiona
 Multivariable Regressiona
 Multivariable Regressiona
TSE status aOR 95% CI p-Value aOR 95% CI p-Value aOR 95% CI p-Value
Child is affectionate and tender
 No TSE (Ref) (Ref) (Ref) (Ref) (Ref) (Ref) (Ref) (Ref) (Ref)
 Household smoker—no home TSE 1.09 0.95–1.24 .21 1.00 0.81–1.22 .97 1.15 0.97–1.37 .10
 Household smoker—home TSE 1.74 1.18–2.58 .006 1.97 1.04–3.74 .04 1.64 0.99–2.70 .05
Child bounces back quickly
 No TSE (Ref) (Ref) (Ref) (Ref) (Ref) (Ref) (Ref) (Ref) (Ref)
 Household smoker—no home TSE 1.10 0.98–1.22 .10 0.94 0.79–1.12 .49 1.21 1.05–1.40 .007
 Household smoker—home TSE 1.33 0.93–1.91 .12 1.18 0.64–2.16 .60 1.46 0.93–2.29 .10
Child shows interest and curiosity
 No TSE (Ref) (Ref) (Ref) (Ref) (Ref) (Ref) (Ref) (Ref) (Ref)
 Household smoker—no home TSE 1.09 0.95–1.25 .21 1.00 0.80–1.24 .97 1.16 0.97–1.37 .10
 Household smoker—home TSE 1.81 1.23–2.68 .003 1.22 0.59–2.51 .60 2.24 1.40–3.59 .001
Child smiles and laughs
 No TSE (Ref) (Ref) (Ref) (Ref) (Ref) (Ref) (Ref) (Ref) (Ref)
 Household smoker—no home TSE 1.10 0.94–1.29 .22 0.92 0.72–1.17 .48 1.26 1.03–1.54 .03
 Household smoker—home TSE 1.77 1.13–2.77 .01 0.92 0.38–2.24 .86 2.43 1.43–4.11 .001
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Note. NSCH = National Survey on Children’s Health; TSE = tobacco smoke exposure; aOR = adjusted odds ratio; CI = confidence interval; Ref = reference group.

a

Adjusted for child age, sex, race/ethnicity, premature birth, overall health status, parent education, and family structure and federal poverty level.

TSE Status and Temperament among 0- to 2-Year-Olds

Nearly half (49.6%) of children were 0–2 years old (n = 6,706), and of those, 12.6% (n = 733) lived with a smoker with no home TSE and 0.9% had home TSE (n = 47). Unadjusted (OR = 2.04, 95% CI = 1.10–3.80) and adjusted (aOR = 1.97, 95% CI = 1.04–3.74) results indicated that 0- to 2-year-olds who lived with a smoker with home TSE were more likely to not always be affectionate and tender with their parent than 0- to 2-year-olds with no TSE (see Tables II and III).

TSE Status and Temperament among 3- to 5-Year-Olds

A total of 50.4% of children were 3–5 years old (n = 7,639), and of those, 12.5% (n = 1,003) lived with a smoker with no home TSE and 1.3% had home TSE (n = 84). Unadjusted results indicated that compared to 3- to 5-year-olds with no TSE, 3- to 5-year-olds who lived with a smoker with no home TSE and with home TSE were at increased odds to not always: be affectionate and tender with their parent, show interest and curiosity in learning new things, and smile and laugh. Those who lived with a smoker with no home TSE were also more likely to not always bounce back quickly when things did not go their way. Adjusted results indicated that compared to those with no TSE, 3- to 5-year-olds who lived with a smoker with no home TSE were more likely to not always: bounce back quickly when things did not go their way (aOR = 1.21, 95% CI = 1.05–1.40) and smile and laugh (aOR = 1.26, 95% CI = 1.03–1.54; see Table III). Children who lived with a smoker with home TSE were more likely to not always: show interest and curiosity in learning new things (aOR = 2.24, 95% CI = 1.40–3.59) and smile and laugh (aOR = 2.43, 95% CI = 1.43–4.11).

Discussion

The results of this study lend support to literature demonstrating that children who live with family members who smoke and are exposed to tobacco smoke face risks for developmental problems (Luk et al., 2018; Max et al., 2013; Rosenthal & Weitzman, 2011). Our findings indicate children with TSE may experience early health problems, which is consistent with the U.S. Surgeon General’s (U.S. Department of Health and Human Services, 2014) exhortations indicating that there is no safe level of TSE. Current findings add to existing literature showing that in addition to potential cognitive and behavioral risk factors (Lee et al., 2019; Max et al., 2013; Twardella et al., 2010), TSE may pose risks in terms of factors related to temperament, which may impact children’s positive interactions with their parents. These findings are important given the strong relationships between childhood temperament, emotion regulation, and developmental trajectories (Beekman et al., 2015; Klein & Finsaas, 2017; Kozlova et al., 2020).

As hypothesized, this research demonstrates that children residing in homes with a smoker, with and without home TSE, are at increased odds for experiencing early child temperament issues, even after controlling for covariates. Overall, children residing with a household smoker with home TSE were reportedly more apt to not be affectionate and tender with parents, and were not always showing interest and curiosity in learning new things, or smiling and laughing, in comparison to children with no TSE. Thus, we found that TSE is a risk factor that may affect positive social and emotional development. This is consistent with literature indicating that young children face developmental risks when there is smoking at home (Herrmann et al., 2008; Rosenthal & Weitzman, 2011; Zhou et al., 2014). Informing smokers of the risk in terms of emotional sharing may help them to bridge a gap and engage in more affectionate exchanges with their children, in turn, leading to positive social and emotional trajectories. Facilitating positive exchanges may improve children’s positive affect, so they smile and laugh more frequently. Smokers who allow smoking in the home may need to encourage learning, by introducing new experiences for children. There were no differences for 0- to 5-year-olds bouncing back quickly after covariate adjustment, which may suggest children could benefit from positive experiences and resume a positive trajectory on other indicators of temperament.

When a deeper dive was extended to age ranges, we found that preschoolers were more at risk in terms of negative impact on temperament when they lived with a smoker without and with home TSE. As posited, 3- to 5-year-olds living with a smoker with no home TSE had increased odds of not always bouncing back quickly or smiling and laughing, two key variables related to positive functioning. Additionally, residing with a smoker with home TSE increased the odds of 3- to 5-year-olds not always showing curiosity about learning new things or smiling and laughing compared to 3- to 5-year-olds with no TSE. Thus, home smoking status appears to be a risk for factors related to positive temperament. In cases where there was home TSE, 3- to 5-year-olds were at further risk for infrequent expression of behaviors related to positive development including showing interest and curiosity and smiling and laughing. Fewer risk factors were identified in the infancy and toddler age group. However, 0- to 2-year-olds were less likely to be viewed as being tender and affectionate with their parent if they had postnatal home TSE. The aforementioned differences regarding temperament were not evident when 0- to 2-year-olds lived with a smoker with no home TSE. This may indicate that home TSE is a risk factor for a lack of parent–child engagement at home or a lack of parent knowledge to facilitate positive child development. Further research into “why” home TSE confers additional risk is needed. On the other hand, our results suggest that home TSE is exerting a negative influence at the child level, negatively affecting their behavioral health such that the child is not as engaged in his/her environment and with others. In either case, TSE as a risk factor remains important to explore, to understand how homes with TSE are having a negative effect on child social and emotional development. Hence, perhaps parent education about ways to positively impact children’s development through showing affection, engaging in dyadic play, and introducing new learning activities would improve interactions, and thereby positively influence child temperament. Further, parents who smoke, particularly low-income smokers, may have higher life stress levels, lower social support, and inadequate resources (Hiscock et al., 2012), which may lead to suboptimal parent–child interactions. Thus, findings from this study may be used to encourage child and pediatric psychologists to review this behavior with parents, and demonstrate positive interactions in parent–child sessions.

A higher proportion of 3- to 5-year-olds lived with smokers with no home TSE and with home TSE. It may be that parents are more likely to quit smoking or establish smoking bans when the child is younger (Kopp et al., 2018), but may resume smoking when the child is older, believing that risks are reduced over time. TSE is a risk factor for conduct problems and negative behaviors in older youth (Pagani & Fitzpatrick, 2013), and educating parents about this link is important. Healthcare professionals should screen for TSE in all young children and provide parents with education on how to reduce TSE with an emphasis on quitting smoking. The Clinical Practice Guideline for Treating Tobacco Use and Dependence 2008 Update Panel, Liaisons, and Staff (2008) provides strategies and recommendations to assist healthcare professionals in delivering effective clinical interventions to reduce tobacco dependence. The guidelines suggest the “5 A’s” of asking about tobacco use and TSE, advising identified users to quit tobacco and stop smoking around others, assessing tobacco users’ willingness to make a quit attempt, assisting those willing to make a quit attempt with the needed information and resources, and arranging follow-up for tobacco users to prevent relapses. Further, parent education should include information on the risks of child TSE with temperament and later child development, and methods to facilitate positive interactions and social and emotional development. One evidence-based intervention that addresses young children’s temperaments and key areas of concern for parents is Parent–Child Interaction Therapy (Lieneman et al., 2017).

Results for associations between TSE and additional sociodemographic factors indicated that children with higher proportions of TSE were non-Hispanic white and black. Prior studies have found white (Hawkins & Berkman, 2014) and black (Yolton et al., 2009) infants are at increased odds of having higher TSE. Research on children ≥3 years old indicates black children have higher rates of biochemically validated TSE than white children (Merianos et al., 2019). In this cross-sectional study, it is not possible to determine why rates were higher for these groups. Longitudinal research will assist in uncovering why TSE is greater for certain risk groups in order to address these existing gaps in related health equity. Results of this study are still valuable, however, in that they provide guidance for professionals in support of continuing to screen for home TSE, especially in parents of at-risk children. Further, results confirm that residing in poverty (Brody et al., 2019), non-traditional family structures (King et al., 2009), and lower parent education (Pisinger et al., 2012) are associated with child TSE. It is important to note that our study inclusion criteria resulted in excluding more children with likely lower socioeconomic status (i.e., low parent education, FPL, and non-traditional family structures). Thus, the results of the deleterious impact of these proxies of socioeconomic status may have been even more severe in terms of health, parent smoking, home TSE, and temperament in a sample of children and parents with low income.

It is noteworthy, that overall, when the child lived with a smoker with home TSE, health risks for children were significant. Similar to prior work, children had higher prevalence of premature birth (Kyrklund-Blomberg et al., 2005) and poor health status (U.S. Department of Health and Human Services, 2014). This may be because these children were likely exposed before birth, leading to poor health, and then they could have continued to be exposed to the negative effects of postnatal TSE. NSCH data were cross-sectional, and thus, these conclusions are speculative. Further longitudinal research examining the negative impact of TSE prenatally and postnatally through the early years is needed to more fully understand the deleterious effects of TSE on child development. Moreover, it is not possible to untangle whether results occurred due to prenatal or postnatal exposure, a common issue in the literature (Rückinger et al., 2010).

Although our study has many strengths including using the two most recent waves of nationally representative NSCH data, we have several limitations to report. NSCH is cross-sectional in nature and causality cannot be ascertained. All NSCH responses are parent reported, and parents may have responded in a socially desirable manner due to the topics of TSE and temperament. Although we were able to assess the three broad dimensions of temperament (Rothbart & Bates, 2006) using the four available parent-reported items, the NSCH did not measure each specific dimension (e.g., perceptual sensitivity) and thus we were unable to assess the variability of each dimension. Temperament is influenced by prenatal factors including maternal substance use and psychiatric problems such as depression and anxiety (Gartstein & Skinner, 2018). Additionally, we used the only two TSE variables available. Parents were not asked about prenatal TSE or amount of current exposure (e.g., number of cigarettes smoked around the child per day), and biochemical measures of TSE were not obtained (e.g., cotinine). Thus, our results do not differentiate prenatal TSE from postnatal TSE or assess other maternal substance use, maternal warmth and sensitivity, or family mental health history due to secondary data limitations. Future studies should consider including these potential covariates.

We found that children ranging from infancy to the preschool ages who lived with a smoker with home TSE were at increased odds of not always demonstrating positive early childhood temperament behaviors. When evaluating specific age groups, 3- to 5-year-olds with home TSE had more pronounced odds of not always displaying these temperament-related behaviors. This represents the importance of parent smoking cessation in addition to implementing complete home and car smoking bans in these young children’s environments. Future research is needed to explore the mechanism underlying the relationship between TSE and temperament problems among 0- to 5-year-olds. This includes assessing parenting behavior in addition to how TSE biologically influences development. It remains critical to assess how living with a smoker and home TSE in early childhood impacts developmental trajectories over time as research shows exposed children may experience difficulties with behavioral functioning well into the elementary school years (Rückinger et al., 2010).

Funding

This work was supported by the National Institute on Drug Abuse (NIH Grant Number K01DA044313 to A.L.M.) and National Institute of Environmental Health Sciences (NIH Grant Numbers R01ES027815 and R01ES030743 to E.M.M.G.).

Conflicts of interest: None declared.

References

  1. Beekman C., Neiderhiser J. M., Buss K. A., Loken E., Moore G. A., Leve L. D., Ganiban J. M., Shaw D. S., Reiss D. (2015). The development of early profiles of temperament: characterization, continuity, and etiology. Child Development, 86(6), 1794–1811. 10.1111/cdev.12417 [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Brody D. J., Lu Z., Tsai J. (2019). Secondhand smoke exposure among nonsmoking youth: United States, 2013-2016. NCHS Data Brief, No. 348. Hyattsville, MD: National Center for Health Statistics. [PubMed]
  3. Buss A. H., Plomin R. (1975). A temperament theory of personality development. Wiley. [Google Scholar]
  4. Carranza Carnicero J. A., Pérez-López J., Del Carmen González Salinas M., Martínez-Fuentes M. T. (2000). A longitudinal study of temperament in infancy: stability and convergence of measures. European Journal of Personality, 14(1), 21–37. https://doi.org/10.1002/(SICI)1099-0984(200001/02)14:13.0.CO; 2-A [Google Scholar]
  5. Chen R., Clifford A., Lang L., Anstey K. J. (2013). Is exposure to secondhand smoke associated with cognitive parameters of children and adolescents?-A systematic literature review. Annals of Epidemiology, 23(10), 652–661. 10.1016/j.annepidem.2013.07.001 [DOI] [PubMed] [Google Scholar]
  6. Child and Adolescent Health Measurement Initiative. (2019). “2018 National Survey of Children’s Health: Guide to Topics and Questions”. Data Resource Center for Child and Adolescent Health, supported by Cooperative Agreement U59MC27866 from the U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau.
  7. Clinical Practice Guideline for Treating Tobacco Use and Dependence 2008 Update Panel, Liaisons, and Staff. (2008). A Clinical Practice Guideline for treating tobacco use and dependence: 2008 update. A U.S. Public Health Service report. American Journal of Preventive Medicine, 35(2), 158–176. 10.1016/j.amepre.2008.04.009 [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Creamer M. R., Wang T. W., Babb S., Cullen K. A., Day H., Willis G., Jamal A., Neff L. (2019). Tobacco product use and cessation indicators among adults—United States, 2018. Mmwr. Morbidity and Mortality Weekly Report, 68(45), 1013–1019. 10.15585/mmwr.mm6845a2 [DOI] [PMC free article] [PubMed] [Google Scholar]
  9. Gartstein M. A., Skinner M. K. (2018). Prenatal influences on temperament development: The role of environmental epigenetics. Development and Psychopathology, 30(4), 1269–1303. 10.1017/S0954579417001730 [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. Gatzke-Kopp L. M., Willoughby M. T., Warkentien S. M., O’Connor T., Granger D. A., Blair C. (2019). Magnitude and chronicity of environmental smoke exposure across infancy and early childhood in a sample of low-income children. Nicotine & Tobacco Research, 21(12), 1665–1672. 10.1093/ntr/nty228 [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Hawkins S. S., Berkman L. (2014). Identifying infants at high‐risk for second‐hand smoke exposure. Child: Care, Health and Development, 40(3), 441–445. 10.1111/cch.12058 [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Herrmann M., King K., Weitzman M. (2008). Prenatal tobacco smoke and postnatal secondhand smoke exposure and child neurodevelopment. Current Opinion in Pediatrics, 20(2), 184–190. 10.1097/MOP.0b013e3282f56165 [DOI] [PubMed] [Google Scholar]
  13. Hiscock R., Bauld L., Amos A., Fidler J. A., Munafò M. (2012). Socioeconomic status and smoking: A review. Annals of the New York Academy of Sciences, 1248(1), 107–123. 10.1111/j.1749-6632.2011.06202.x [DOI] [PubMed] [Google Scholar]
  14. Jacob P., Benowitz N. L., Destaillats H., Gundel L., Hang B., Martins-Green M., Matt G. E., Quintana P. J. E., Samet J. M., Schick S. F., Talbot P., Aquilina N. J., Hovell M. F., Mao J.-H., Whitehead T. P. (2017). Thirdhand smoke: New evidence, challenges, and future directions. Chemical Research in Toxicology, 30(1), 270–294. 10.1021/acs.chemrestox.6b00343 [DOI] [PMC free article] [PubMed] [Google Scholar]
  15. Kabir Z., Connolly G. N., Alpert H. R. (2011). Secondhand smoke exposure and neurobehavioral disorders among children in the United States. Pediatrics, 128(2), 263–270. 10.1542/peds.2011-0023 [DOI] [PubMed] [Google Scholar]
  16. Kagan J., Reznick J. S., Clarke C., Snidman N., Garcia-Coll C. (1984). Behavioral inhibition to the unfamiliar. Child Development, 55(6), 2212–2225. 10.1111/j.1467-8624.1984.tb03916.x [DOI] [Google Scholar]
  17. King K., Martynenko M., Bergman M. H., Liu Y., Winickoff J. P., Weitzman M. (2009). Family composition and children’s exposure to adult smokers in their homes. Pediatrics, 123(4), e559–e564. 10.1542/peds.2008-2317 [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Klein D. N., Finsaas M. C. (2017). The stony brook temperament study: Early antecedents and pathways to emotional disorders. Child Development Perspectives, 11(4), 257–263. 10.1111/cdep.12242 [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Kopp B. T., Hinton A., Lu R., Cooper S., Nagaraja H., Wewers M. E. (2018). Impact of presence of children on indoor tobacco restrictions in households of urban and rural adult tobacco users. Academic Pediatrics, 18(8), 920–927. 10.1016/j.acap.2018.04.002 [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Kozlova E. A., Slobodskaya H. R., Gartstein M. A. (2020). Early temperament as a predictor of child mental health. International Journal of Mental Health and Addiction, 18, 1493–1506. 10.1007/s11469-019-00181-3 [DOI] [Google Scholar]
  21. Kyrklund-Blomberg N. B., Granath F., Cnattingius S. (2005). Maternal smoking and causes of very preterm birth. Acta Obstetricia Et Gynecologica Scandinavica, 84(6), 572–577. 10.1111/j.0001-6349.2005.00848.x [DOI] [PubMed] [Google Scholar]
  22. Lee M., Ha M., Hong Y., Park H., Kim Y., Kim E., Kim Y., Ha E. (2019). Exposure to prenatal secondhand smoke and early neurodevelopment: Mothers and Children’s Environmental Health (MOCEH) study. Environmental Health, 18(1), 22. 10.1186/s12940-019-0463-9 [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Lieneman C. C., Brabson L. A., Highlander A., Wallace N. M., McNeil C. B. (2017). Parent-child interaction therapy: Current perspectives. Psychology Research and Behavior Management, 10, 239–256. 10.2147/PRBM.S91200 [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Luk T. T., Wang M. P., Suen Y. N., Koh D. S., Lam T. H., Chan S. S. (2018). Early childhood exposure to secondhand smoke and behavioural problems in preschoolers. Scientific Reports, 8(1), 15434. 10.1038/s41598-018-33829-6 [DOI] [PMC free article] [PubMed] [Google Scholar]
  25. Mahabee-Gittens E. M., Merianos A. L., Stone L., Tabangin M. E., Khoury J. C., Gordon J. S. (2019). Tobacco use behaviors and perceptions of parental smokers in the emergency department setting. Tobacco Use Insights, 12, 1179173X1984139. 10.1177/1179173X19841392 [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Max W., Sung H., Shi Y. (2013). Attention deficit hyperactivity disorder among children exposed to secondhand smoke: A logistic regression analysis of secondary data. International Journal of Nursing Studies, 50(6), 797–806. 10.1016/j.ijnurstu.2012.10.002 [DOI] [PubMed] [Google Scholar]
  27. Merianos A. L., Jandarov R. A., Choi K., Mahabee-Gittens E. M. (2019). Tobacco smoke exposure disparities persist in U.S. children: NHANES 1999–2014. Preventive Medicine, 123, 138–142. 10.1016/j.ypmed.2019.03.028 [DOI] [PMC free article] [PubMed] [Google Scholar]
  28. Micalizzi L., Knopik V. S. (2018). Maternal smoking during pregnancy and offspring executive function: What do we know and what are the next steps? Development and Psychopathology, 30(4), 1333–1354. 10.1017/S0954579417001687 [DOI] [PMC free article] [PubMed] [Google Scholar]
  29. Murray G. K., Jones P. B., Kuh D., Richards M. (2007). Infant developmental milestones and subsequent cognitive function. Annals of Neurology, 62(2), 128–136. 10.1002/ana.21120 [DOI] [PMC free article] [PubMed] [Google Scholar]
  30. Pagani L. S., Fitzpatrick C. (2013). Prospective associations between early long-term household tobacco smoke exposure and antisocial behaviour in later childhood. Journal of Epidemiology and Community Health, 67(7), 552–557. 10.1136/jech-2012-202191 [DOI] [PubMed] [Google Scholar]
  31. Pisinger C., Hammer-Helmich L., Andreasen A. H., Jørgensen T., Glümer C. (2012). Social disparities in children’s exposure to second hand smoke at home: A repeated cross-sectional survey. Environmental Health, 11(1), 65. 10.1186/1476-069X-11-65 [DOI] [PMC free article] [PubMed] [Google Scholar]
  32. Putnam S. P., Gartstein M. A., Rothbart M. K. (2006). Measurement of fine-grained aspects of toddler temperament: The early childhood behavior questionnaire. Infant Behavior and Development, 29(3), 386–401. 10.1016/j.infbeh.2006.01.004 [DOI] [PMC free article] [PubMed] [Google Scholar]
  33. Rogers J. M. (2009). Tobacco and pregnancy. Reproductive Toxicology, 28(2), 152–160. 10.1016/j.reprotox.2009.03.012 [DOI] [PubMed] [Google Scholar]
  34. Rosenthal D. G., Weitzman M. (2011). Examining the effects of intrauterine and postnatal exposure to tobacco smoke on childhood cognitive and behavioral development. International Journal of Mental Health, 40(1), 39–64. 10.2753/IMH0020-7411400103 [DOI] [Google Scholar]
  35. Rothbart M. K. (1981). Measurement of temperament in infancy. Child Development, 52(2), 569–578. 10.1111/j.1467-8624.1981.tb03082.x [DOI] [Google Scholar]
  36. Rothbart M. K., Ahadi S. A. (1994). Temperament and the development of personality. Journal of Abnormal Psychology, 103(1), 55–66. 10.1037/0021-843X.103.1.55 [DOI] [PubMed] [Google Scholar]
  37. Rothbart M. K., Ahadi S. A., Hershey K. L., Fisher P. (2001). Investigations of temperament at three to seven years: The children’s behavior questionnaire. Child Development, 72(5), 1394–1408. 10.1111/1467-8624.00355 [DOI] [PubMed] [Google Scholar]
  38. Rothbart M. K., Bates J. E. (2006). Temperament. In Damon W., Lerner R., Eisenberg N. (Eds.) Handbook of child psychology: Vol. 3. Social, emotional, and personality development (6th edn, pp. 99–166). Wiley. [Google Scholar]
  39. Rückinger S., Rzehak P., Chen C., Sausenthaler S., Koletzko S., Bauer C., Hoffman U., Kramer U., Berdel D., von Berg A., Bayer O., Wichmann H. E., von Kries R., Heinrich J. (2010). Prenatal and postnatal tobacco exposure and behavioral problems in 10-year-old children: Results from the GINI-plus prospective birth cohort study. Environmental Health Perspectives, 118(1), 150–154. 10.1289/ehp.0901209 [DOI] [PMC free article] [PubMed] [Google Scholar]
  40. Slykerman R. F., Thompson J. M. D., Clark P. M., Becroft D. M. O., Robinson E., Pryor J. E., Wild C. J., Mitchell E. A. (2007). Determinants of developmental delay in infants aged 12 months. Paediatric and Perinatal Epidemiology, 21(2), 121–128. 10.1111/j.1365-3016.2007.00796.x [DOI] [PubMed] [Google Scholar]
  41. U.S. Census Bureau. (2018). 2017 National Survey of Children’ Health methodology report. https://www.childhealthdata.org/learn-about-the-nsch/methods. Accessed 28 January 2020.
  42. U.S. Census Bureau. (2019). 2018 National Survey of Children’s Health Methodology report. https://www.childhealthdata.org/learn-about-the-nsch/methods. Accessed 28 January 2020.
  43. Thomas A., Chess S. (1977). Temperament and development. Brunner/Mazel. [Google Scholar]
  44. Twardella D., Bolte G., Fromme H., Wildner M., von Kries R; the GME Study Group (2010). Exposure to secondhand tobacco smoke and child behaviour – Results from a cross-sectional study among preschool children in Bavaria. Acta Paediatrica, 99(1), 106–111. 10.1111/j.1651-2227.2009.01522.x [DOI] [PubMed] [Google Scholar]
  45. U.S. Department of Health and Human Services. (2014). The health consequences of smoking - 50 years of progress: A report of the Surgeon General. U.S. Department of Health and Human Services, Office of the Surgeon General. [Google Scholar]
  46. Yolton K., Khoury J., Xu Y., Succop P., Lanphear B., Bernert J. T., Lester B. (2009). Low-level prenatal exposure to nicotine and infant neurobehavior. Neurotoxicology and Teratology, 31(6), 356–363. 10.1016/j.ntt.2009.07.004 [DOI] [PMC free article] [PubMed] [Google Scholar]
  47. Zhou S., Rosenthal D. G., Sherman S., Zelikoff J., Gordon T., Weitzman M. (2014). Physical, behavioral, and cognitive effects of prenatal tobacco and postnatal secondhand smoke exposure. Current Problems in Pediatric and Adolescent Health Care, 44(8), 219–241. 10.1016/j.cppeds.2014.03.007 [DOI] [PMC free article] [PubMed] [Google Scholar]

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