Background Adherence with inhaled controller medications for asthma is known to be highly variable with many patients taking fewer doses than recommended for consistent control of lung inflammation. Adherence also worsens as children become teenagers, although the exact causes are not well established. Objective To use focus group methodology to examine beliefs, feelings, and behaviors about inhaled asthma controller medication in adolescents and young adults who had previously participated in a longitudinal study of asthma treatment adherence and outcome in order to develop more effective management strategies. Methods Twenty-six subjects participated in 6 focus groups comprised of 3-5 young adults (age range 12-20 years). Verbatim transcripts of these groups were analyzed using the long-table method of content analysis to identify key themes raised by participants. Results A variety of beliefs, feelings and behaviors influence the adolescent’s decision about how to use their asthma medication. Some of the adolescents understood the importance of daily medication and were committed to the treatment plan prescribed by their provider. Poorer adherence was the product of misinformation, incorrect assumptions about their asthma, and current life situations. Conclusions These results, by highlighting potential mechanisms underlying both better and worse adherence inform the development of strategies to improve adherence behavior in adolescents and young adults with asthma. Knowledge of the specific beliefs, feelings and behaviors that underlie adolescents’ use of inhaled asthma controller medication will help providers maximize treatment adherence in this notoriously difficult patient population.

Introduction: Asthma is often under-diagnosed and under-treated in primary care. The Colorado Asthma Toolkit Program was initiated to establish a method for improving asthma care by providing to primary care practices coaching, training, and support for (1) evidence-based asthma diagnosis and treatment, and (2) education and activation of patients toward effective self-management of their illness.Methods: A collaborative program was initiated involving 2 academic medical institutions and the High Plains Research Network, a primary care practice-based research network in eastern Colorado. Focus groups were conducted with rural Colorado patients and health care clinicians to assess need and determine the most effective intervention strategies. Two intertwined training programs, or "toolkits," were subsequently developed, one each for health care clinicians and patients. Clinicians received 3 coaching sessions conducted by 2 nurses in the practice that included training in guideline-based methods for evaluation and treatment of asthma, coaching to assist practices in implementing these methods, and training in communication techniques to promote asthma self-management. Practices were also given a spirometer and trained in its use and interpretation. Patient self-management toolkits were provided to clinicians, who were trained to use the materials to educate patients and increase treatment adherence. Evaluations were based on practice interviews 1 to 3 months after coaching.Results

Exposure to environmental tobacco smoke (ETS) is most often estimated using questionnaires, but they are unreliable. Biomarkers can provide valid information on ETS exposure, the preferred biomarker being cotinine. However, no reference range of hair cotinine exists to distinguish among active, passive, and unexposed nonsmokers. This study identifies cutoffs to validate cotinine as a marker for exposure to ETS. Data were obtained from six databases (four US, one Canada, one France). Active smoking and exposure to ETS were measured in the hair of women of reproductive age, pregnant women, their children, and neonates. Subjects were classified into active smokers, passively exposed to ETS, and unexposed nonsmokers. A total of 1746 cases were available for analysis. For active smokers, mean hair cotinine concentrations (95% confidence interval) were 2.3 to 3.1 ng/mg for nonpregnant women and 1.5 to 1.9 ng/mg for pregnant women. In the group of passive smokers, mean hair cotinine concentrations were 0.5 to 0.7 ng/mg for nonpregnant women, 0.04 to 0.09 ng/mg for pregnant women, 0.9 to 1.1 for children, and 1.2 to 1.7 for neonates. Among unexposed nonsmokers, mean hair cotinine was 0.2 to 0.4 ng/mg in nonpregnant women, 0.06 to 0.09 ng/mg in pregnant women, and 0.3 to 0.4 ng/mg in children. Cutoff values for hair cotinine were established to distinguish active smokers from passive or unexposed (0.8 ng/mg for nonpregnant women and 0.2 ng/mg for pregnant women). A cutoff value of 0.2 ng/mg was accurate in discriminating between exposed children and unexposed. These new values should facilitate clinical diagnosis of active and passive exposure to tobacco smoke. Such diagnosis is critical in pregnancy and in a large number of tobacco-induced medical conditions.

Objective-To establish the relationship between adherence and symptom control in adolescents and young adults with asthma.Design-This was a telephone-interview study conducted as an ancillary project to the Childhood Asthma Management Program Continuation Study (CAMPCS).Setting-The six monthly interviews were conducted from a single calling center in Denver, Colorado.Participants-Included were 756 adolescent and young adult participants in CAMPCS, who upon entry into the original study were diagnosed to have mild to moderate asthma.Outcome measures-Participants were queried about medication use and symptom control within each one-month interview window. Strategies adopted to improve self-report accuracy included use of repeat interviews, confidential reporting to staff unknown to the participants, and use of questions focused on recent behavior.Results-Only participants who were consistently on or off ICS medication for the entire six-month study interval were included. Three groups of patients were contrasted: those not on ICS medication (n=420), those on ICS with High Adherence (at least 75% of medication taken, n=90), and those on ICS with Low/Medium adherence (less than 75% taken, n=148). Participants in the Low/Medium adherence group reported on average less symptom control and more variability in wheezing, awakening at night, missed activities, and beta 2 agonist use over the 6-month period, although most in this group perceived their asthma to be under good control.Conclusion-Despite extensive patient education and support, diminished ICS adherence was frequent and undermined symptom control in this group of adolescents and young adults with mild to moderate asthma.

Exposure to secondhand smoke (SHS) harms all children's health, especially children with asthma. Yet, children with asthma are as likely to live with smokers as healthy children. Household smoking bans are being advocated to reduce children's harm from SHS. To measure the effect of household smoking bans on child SHS exposure and to examine correlates of strict smoking bans in a low-income, diverse sample, 91 children with asthma were matched to 91 healthy children. All had at least one smoker living in their homes. Nicotine dosimeters, child cotinine assays, and maternal reports quantified child SHS exposures. Maternal reports of household smoking rules, behaviors, and beliefs, and other family characteristics were also gathered. The presence of a strict household smoking ban vastly reduced children's SHS exposures and was associated with fewer cigarettes smoked by the mother and by other family members, the belief that SHS was a personal health risk, having children with asthma, and living in a single-family home. Many children are exposed to high levels of SHS at home. Strict household smoking bans greatly decrease, but do not eliminate children's SHS exposure. Even in disadvantaged families, mutable factors were associated with strict smoking bans. Increased dissemination and use of established public health strategies are needed to reduce children's SHS exposures.