2007 Progress Report: A Randomized Controlled Trial of Behavior Changes in Home Exposure Control

EPA Grant Number: R832139C002
Subproject: this is subproject number 002 , established and managed by the Center Director under grant R832139
(EPA does not fund or establish subprojects; EPA awards and manages the overall grant for this center).

Center: Johns Hopkins Center for Childhood Asthma in the Urban Environment
Center Director: Breysse, Patrick N.
Title: A Randomized Controlled Trial of Behavior Changes in Home Exposure Control
Investigators: Breysse, Patrick N.
Current Investigators: Butz, Arlene
Institution: The Johns Hopkins University
EPA Project Officer: Callan, Richard
Project Period: November 1, 2003 through October 31, 2008 (Extended to October 31, 2010)
Project Period Covered by this Report: November 1, 2006 through October 31, 2007
RFA: Centers for Children's Environmental Health and Disease Prevention Research (2003) RFA Text |  Recipients Lists
Research Category: Children's Health , Health Effects , Health


The original goals of this community-base prevention project were to conduct a randomized controlled trial of the effectiveness of an environmental intervention based on home air filters and a smoking behavior modification behavioral intervention on reducing hazardous exposures and their adverse health effects.

An additional goal of the project was to complete the analysis of the intervention trial conducted during years 02-05 and to publish these results.

We conducted a randomized controlled trial of methods to reduce home environmental exposure in the homes of asthmatic children living in the inner city.

Progress Summary:

Progress on the New Intervention study years 06-09: The study protocol was reviewed and approved by the EPA IRB. Recruitment started 10/2006 after a delay in receiving General Clinical Research Center (GCRC) approval to conduct clinic evaluation visits. To date we have enrolled 48 subjects who have completed their baseline clinic and home indoor air monitoring evaluations. Twelve families have completed the 6 month intervention including follow-up clinic and home evaluations. Retention of subjects is high at 80%. To date, a total of 120 home visits have been completed by the intervention nurse for all three groups (Group A: combination of behavioral techniques to reduce ETS and air filtration, Group B: air filtration alone and Group C: no air filtration or behavioral intervention (delayed air filtration). The primary outcome remains indoor PM10, PM2.5 and nicotine with secondary outcomes of child’s heath and urine cotinine measurements.

Table 1: Exposure Measures: PM2.5 and 10, Urine Cotinine and Airborne Nicotine at baseline


Median (IQR)

PM 2.5 (ug/m3) n=39

30.7 (22.1-61.1)

PM 10 (ug/m3) n=39

55.9 (36.9-07.4)

Urine Cotinine ng/ml n=37

21.3 (9.3-36.2)

Airborne Nicotine (ug/m3) n=35

1.43 (0.32-3.1)

Asthma morbidity is high in this group of children (Table 2). The median number of attacks of wheezing within the last 2 months was 4 days. Most children (82%) reported cough at night without a cold or chest congestion and half report chest congestion or cough frequently at four or more days per week for at least 3 months. Over half (52%) reported an ED visit and 34% an unscheduled visit within the past 6 months for asthma. Despite this high morbidity only 48% reported use of inhaled corticosteroids in the past 2 weeks. Family history of asthma was high for both parents (mother: 43% and father: 40%).

Table 2: Baseline Child Health Measures N=44

Health Status Characteristics

Median (IQR)

Number of attacks of wheezing last 12 months
Median (IQR)

4 (3-6

Days with Wheeze, Cough Chest Tightness last 2 Weeks

2 (1-3.5)

Nights of awakening due to asthma (N=35)

1 (0-2)

Days slowed/stopped activity (N=42)

2 (0-5)


N (%)

Awakened due to wheezing past 12 months
< 1 night per week
1 or more nights

11 (25)
10 (23)
23 (521)

Wheeze and Breathless symptoms last 12 months
With exercise (Yes)
Without exercise (Yes)
With Cold (Yes)
Without Cold (Yes)

38 (86)
21 (48)
40 (91)
28 (64)

Cough at night with NO cold or chest infection

36 (82)

Awakened at night with SOB, ever

31 (70)

Awakened at night with chest tightness ever

33 (75)

Chest congestion or cough 4+ days/week at least 3 months out of a year

22 (51)

Health Events Last 2 weeks or 6 months

N (%)

ED visit within last 6 months

23 (52)

Unscheduled doctor visit for asthma last 6 months

15 (34)

Degree of Limitation of activity with moderate activity
Very limited
Some limited
A little limited
Not limited

13 (30)
5 (12)
22 (51)

Medication Use

Median (IQR)

Albuterol MDI Use (# days/2 weeks)

3 (0-14)

Albuterol Neb treatments (#days/2 weeks)

0 (0-1)

Inhaled Corticosteroids Use past 2 weeks N (%)

21 (48)

Intal past 2 weeks

2 (5)

Leukotriene Modifier Use past 2 weeks
Yes (Singulair)

14 (32)


N (%)

Family Atopy History
Mother asthma N=42
Mother hay fever N=43
Mother allergic eczema N=42
Father asthma N=42
Father hay fever N=42
Father allergic eczema N=42

18 (43)
7 (16)
9 (21)
17 (40)
6 (14)
7 (17)

Environmental Tobacco Smoke (ETS) Exposure Characteristics at Baseline.
Of note, most caregivers reported smoking (68%) and over half (57%) reported smoking in the home on a daily basis (Table 3). The caregiver’s bedroom was the primary site of smoking in the home and 30% of children were exposed to ETS in a car. Smoking outside of the home was the most common change reported by caregivers at baseline and three quarters reported they were successful or very successful in keeping their child away from tobacco smoke. Over half (55%) of caregivers reported use of candles or incense in the home.

Table 3. Environmental Tobacco Smoke Exposure Characteristics in Home (N=44)


n/N (%)

Caregiver currently smokes

30/44 (68)

Caregiver # cigs/day (n = 30) med (IQR)

9 (5-10)

Caregiver #cigs/day in home (n=30) med (IQR)

5 (2-10)

Caregiver frequency of smoking in home



1 (3)


6 (20)


6 (20)

Always (daily)

17 (57)

Caregiver smoking location


Living/TV room

15/30 (50)


10/30 (33)

Dining room

7/30 (23)

Your bedroom

22/30 (73)

Child’s bedroom

0 (0)


4/30 (13)

Child exposed to ETS in car (Yes)

13/44 (30)

Other people smoke in the home

35/44 (80)

Who else smokes in home



16/35 (45)


1/35 (3)


12/35 (34)


1/35 (3)

Regular visitor

5/35 (14)

Total # cigs/day smoked by everyone, median(IQR) n=42

10 (5-20)

How often child exposed to ETS, 2 weeks


Almost never

6/44 (14)


7/44 (16)


11/44 (25)

Almost always

20/44 (45)

Changes In Smoking Behavior

n/N (%)

Ever made changes due to cig smoke

38/43 (88)

What were changes?


Stopped smoking

1/38 (3)

Reduced smoking

7/38 (18)

Smoke outside the home

22/38 (58)

Not smoking in child’s bedroom

3/38 (8)

Not smoking in the same room the child is in

19/38 (50)

How successful in keeping child away from smoke?


Not at all

8/44 (18)


3/44 (7)


25/44 (57)

Very successful

8/44 (18)

After completion of questionnaires, FEV1 and allergen skin tests, home inspection and measurement of home air pollutants and allergens, 100 asthmatic children aged 6-12 years were randomized to a treatment (home based education, cockroach and rodent extermination, mattress and pillow encasings, and HEPA air cleaner) and control (treated at the end of the 1 year trial). Outcome was assessed with home evaluations at 6 and 12 months, clinic evaluation at 12 months and repeated telephone interviews. Measurements and Main Results: In the treatment group 84% received cockroach extermination and 75% used the air cleaner. PM10 fell by up to 39% in the treatment group, but increased in the control group (p<0.001). Cockroach allergen fell by 43 %. Symptoms increased in the control group and decreased in the treatment group (p=0.04).

Future Activities:

We will continue recruiting to meet our goal of 150 families and continue conducting follow-up clinic evaluations and collection of indoor PM2.5, PM10, air nicotine levels at baseline and at the 6 month follow-up. Data cleaning and preliminary analyses will be conducted and discussed in weekly data meetings. We plan to submit preliminary results at national meetings (American Thoracic Society, American Academy of Allergy, Asthma and Immunology and Ambulatory Pediatric Society) in YR10.

Journal Articles on this Report : 7 Displayed | Download in RIS Format

Other subproject views: All 31 publications 31 publications in selected types All 30 journal articles
Other center views: All 113 publications 113 publications in selected types All 110 journal articles
Type Citation Sub Project Document Sources
Journal Article Butz AM, Tsoukleris M, Donithan M, Hsu VD, Mudd K, Zuckerman IH, Bollinger ME. Patterns of inhaled antiinflammatory medication use in young underserved children with asthma. Pediatrics 2006;118(6):2504-2513. R832139 (2007)
R832139 (Final)
R832139C002 (2007)
R832139C002 (Final)
  • Full-text from PubMed
  • Abstract from PubMed
  • Associated PubMed link
  • Full-text: Pediatrics-Full Text HTML
  • Abstract: Pediatrics-Abstract
  • Other: Pediatrics-Full Text PDF
  • Journal Article Butz AM, Tsoukleris MG, Donithan M, Hsu VD, Zuckerman I, Mudd KE, Thompson RE, Rand C, Bollinger ME. Effectiveness of nebulizer use--targeted asthma education on underserved children with asthma. Archives of Pediatric and Adolescent Medicine 2006;160(6):622-628. R832139 (2007)
    R832139C002 (2006)
    R832139C002 (2007)
  • Full-text from PubMed
  • Abstract from PubMed
  • Associated PubMed link
  • Abstract: Unbound Medicine - abstract
  • Journal Article Butz AM, Walker J, Pulsifer M. Shared Decision Making in Children with Asthma. Pediatric Nursing 2007;33(2):111-116. R832139 (Final)
    R832139C002 (2007)
  • Full-text from PubMed
  • Abstract from PubMed
  • Associated PubMed link
  • Journal Article Butz A. Evidence-Based Practice: What is the Evidence for Medication Adherence in Children? Journal of Pediatric Health Care 2006;20(5):338-341. R832139 (2007)
    R832139C002 (2007)
    not available
    Journal Article Garg A, Serwint J, Higman S, Kanof A, Schell D, Colon I, Butz A. Self-Efficacy at Smoking Cessation Counseling Parents in Primary Care: An Office-Based Intervention for Pediatricians and Family Physicians. Clinical Pediatrics 2007;46(3):252-257. R832139 (2007)
    R832139C002 (2007)
    not available
    Journal Article Mudd K, Bollinger ME, Hsu VD, Donithan M, Butz A. Pharmacy fill patterns in young urban children with persistent asthma. Journal of Asthma 2006;43(8):597-600. R832139 (2007)
    R832139C002 (2007)
    not available
    Journal Article Winkelstein ML, Quartey R, Pham L, Lewis-Boyer L, Lewis C, Hill K, Butz A. Asthma education for rural school nurses: resources, barriers, and outcomes. Journal of School Nursing 2006;22(3):170-177. R832139 (2007)
    R832139C002 (2006)
    R832139C002 (2007)
  • Abstract from PubMed
  • Full-text: Sage Publications - full text html
  • Abstract: Sage Publications
  • Other: Sage Publications - abstract
  • Supplemental Keywords:

    RFA, Health, Scientific Discipline, INTERNATIONAL COOPERATION, ENVIRONMENTAL MANAGEMENT, Health Risk Assessment, Risk Assessments, Disease & Cumulative Effects, Biochemistry, Children's Health, Environmental Policy, Atmospheric Sciences, Ecological Risk Assessment, Risk Assessment, asthma, environmental health, health effects, air pollutants, air toxics, community-based intervention, age-related differences, airway disease, children, Human Health Risk Assessment, air pollution, human exposure, children's environmental health, ambient particulates, disease, airborne urban contaminants

    Progress and Final Reports:

    Original Abstract
  • 2004 Progress Report
  • 2005 Progress Report
  • 2006 Progress Report
  • 2008
  • 2009
  • Final Report

  • Main Center Abstract and Reports:

    R832139    Johns Hopkins Center for Childhood Asthma in the Urban Environment

    Subprojects under this Center: (EPA does not fund or establish subprojects; EPA awards and manages the overall grant for this center).
    R832139C001 The Epidemiology of Susceptibility to Airborne Particulates and Allergens to Asthma in African Americans
    R832139C002 A Randomized Controlled Trial of Behavior Changes in Home Exposure Control
    R832139C003 Mechanisms of Particulate-Induced Allergic Asthma
    R832139C004 Dendritic Cell Activation by Particulate Matter and Allergen