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  News/Maristpoll, notes that only16% of marijuana users cite  “ tohavefun ” astheirreasonforusing;more (19%) cite pain relief. 6 Pro 󿬁 table industries carry con-siderable clout in state capitols;pro 󿬁 table industries with a rabidfan base, all the more so. LEGALIZING ANINDUSTRY Legalizinganindustryhasmanyconsequences. Fiala et al. give usa baseline regarding one, namelyaggressive marketing efforts. Iagree that a comprehensive publichealth response should contem-plate advertising restrictions, butfear that much more will beneeded if legalization involvesa for-pro 󿬁 t industry. There aremany other, safer ways to legalizemarijuana, such as restrictingsupplytoagovernmentmonopolyor to nonpro 󿬁 t organizationswhose charters reserve a majorityof seats on their governing boardsfor public healthand childwelfareadvocates and that de 󿬁 ne their mission as meeting existing de-mand (to undercut the blackmarket) without undertakingmarketing efforts designed toincrease consumption. 7  Jonathan P. Caulkins, PhD  REFERENCES 1. National Academies of Sciences,Engineering, and Medicine. The healtheffects of cannabis and cannabinoids: thecurrent state of evidence and recom-mendations for research. Washington,DC: National Academies Press; 2017.2. Richter KP, Levy S. Big marijuana  —  lessons from big tobacco.  N Engl J Med  .2014;371(5):399  –  401.3. Pacula RL, Kilmer B, Wagenaar AC,Chaloupka FJ, Caulkins JP. Developingpublic health regulations for marijuana:lessons from alcohol and tobacco.  Am J Public Health . 2014;104(6):1021  –  1028.4. Kleiman MAR.  Against Excess: Drug Policy for Results . New York, NY: Basic-Books; 1992.5.CrombieN.Fifteen Oregonians tappedto help shape rules for regulatingmarijuana.  The Oregonian . May 4, 2015.Available at: http://www.oregonlive.com/marijuana/index.ssf/2015/05/meet_the_people_who_will_advis.html.Accessed September 25, 2017.6. Ingraham C. 11 charts that showmarijuana has truly gone mainstream. Washington Post  . April 19, 2017. Availableat: https://www.washingtonpost.com/news/wonk/wp/2017/04/19/11-charts-that-show-marijuana-has-truly-gone-mainstream/?utm_term=.ef47abaa0575.Accessed November 8, 2017.7. Caulkins JP, Kilmer B, Kleiman MAR,et al. Considering marijuana legalization:insights for Vermont and other jurisdic-tions. Santa Monica, CA: RAND; 2015. Managing Childhood Asthma as aStrategy to Break the Cycle of Poverty See also Dong et al., p. 103. As the second most commonchronic disease of children  —  surpassed only by tooth decay andcavities  —  asthma is a health prob-lem that warrants new perspectivesandapproachestotreatment.Therearesigni 󿬁 cantdisparitiesbyraceandsocioeconomic status, and the coststo children, families, and the healthsystem are substantial. PREVALENCE The documented prevalenceof asthma in children in theUnitedStatesdoubledfrom1980to 1995, increased more slowlyfrom 2001 to 2010, and seems tohave plateaued in recent years. 1 Nationally,8.4%ofchildrenhaveasthma diagnoses, but studieshaveshownratescloserto30%insome high-poverty urban areas,like Harlem, New York, andparts of Detroit, Michigan(http://bit.ly/2yJVWhr ). 2,3 Trends have shown persistentbut decreasing racial dispar-ities in children hospitalizedfor asthma (2001  –  2010),but no concurrent improve-ment for asthma death rates.Among children with asthma,Black children were four times more likely to die of asthmathan White children. 4 COST The annual cost of asthma intheUnitedStates(collectivelyfor adults and children) is estimatedto exceed $56 billion. Most costsare directly related to treatment,and include medication, emer-gency department visits, andhospital stays. A smaller pro-portion is attributed to indirectcosts, like missed work days andloss of productivity (http://bit.ly/2zwpKh3). These calcula-tions, although weighty, don ’ teven begin to cover the potentialimpact that uncontrolled asthmacan have on kids  —  through de-creased quality of life, comor-bidities, and negative impacton learning outcomes. Poorlycontrolled asthma is a well-documented health barrier tolearning, primarily through itsimpact on sleep and attendance.Over time, impaired learningcan lead to poor third-gradereading and math scores, whichare associated with decreasedlikelihood of graduation and,ultimately, with reduced earningpotential. 5 Inessence,unlesswecansigni 󿬁 cantly improve treatment  —  and access to treatment  —  asthma isand will be a driving factor in thecycleofpovertyformanychildren. CLINICAL CARE Certainlyclinicalcareneedstobe optimized, and there is muchroom for improvement, butevidence-based guidelines for management of asthma areamong the strongest and mostwidely used in pediatric care. 6 Although quality measures fo-cusedonpediatriccareareusuallyfew in national data sets, metricsfor asthma that apply to childrenare typically among those in-cluded. The Asthma ControlTest is widely endorsed as aneffective and standardized way tomeasure and track the control andeffectiveness of treatment in indi-vidual patients. We can still dobetter, but in many ways there ABOUT THE AUTHOR Delaney Gracy is with Children’s Health Fund, New York, NY. Correspondence should be sent to Delaney Gracy, Chief Medical Of    󿬁  cer, Children ’ s HealthFund, 215 W. 125th St, Suite 301, New York, NY 10027 (e-mail: dgracy@chfund.org  ).Reprints can be ordered at  http://www.ajph.org  by clicking the   “   Reprints ”  link.This editorial was accepted October 15, 2017.doi: 10.2105/AJPH.2017.304195  AJPH  EDITORIALS January 2018, Vol 108, No. 1  AJPH  Gracy   Editorial  21  has been focus, standardization,creation of best practices, and im-provement in the clinical man-agement of asthma in children. MANAGEMENT And yet, families are clearlystill struggling, and costs relatedto poor asthma control are thedrivers of the massive asthma-related expense burden to thehealth care system. Asthmamanagement ishard.Patientsandcaregivers need to have a fairlygood understanding of physiol-ogy. They also must manageinhaled medications (often mul-tiple) that require good tech-nique for optimal effect, learn topredict and respond to seasonalpatterns and other illnesses thatcan perpetually change asthmamedication needs, and often dealwith fear, stigma, and errone-ouslylowexpectationsfordiseasemanagement potential. Addi-tionally, parents and caregiversmust coordinate with, providemedication for, and informschools and anyone else whocares for the child about their child ’ sspeci 󿬁 cneedsandtriggers.Behavior change for diseasemanagement is always dif  󿬁 cult.But for a child to achieve goodasthma control, not only thepatient likely needs to changebehavior, but also the caregiver,and other people in the house-hold as well. If the child ispersistently exposed to their triggers  —  such as cigarettesmoke, perfume, cockroaches,or even pets  —  good control andgood outcomes may be verydif  󿬁 cult to achieve. SUPPORTIVEINTERVENTIONS And so we must think outsideof the box  —  or more literally,outside of the clinic  —  for sup-portive interventions. Severalhome-visiting programs focusingon trigger identi 󿬁 cation, abate-ment, and management haveshown promising evidence of impact  —  on asthma control for patients, on quality of life for patientsandtheirfamilies,andon 󿬁 nancialreturnoninvestmentfor asthma-related costs to the healthsystem. 7 A home-visiting, envi-ronmentalinterventionapproachis a major shift for health care inthe United States. We face thequestions we must always con-sider when making treatment or service delivery changes based onexternal data or a pilot program ’ ssuccess. How do we know if a pilot program will have gen-eralizable results? How do weknow when, where, and under what conditions it will or won ’ twork? And if I am the one im-plementing,howdoIknowhowI am doing? Will this service or program be billable and sustain-able, and if not, what data do weneed to advocate for change? Inanevidence-basedandvalue-basedcare era, individually and collec-tively, we have to decide how wewill invest our time and resources. HOME VISITS The article by Dong et al. inthis issue of   AJPH   (p. 103) offersa comparative analysis of severaldifferent pediatric asthma man-agement programs that targettrigger abatement through homevisits. In this study, the authorsshow that all programs assessedimproved patient Asthma Con-trol Test scores and decreasedemergency room utilization.They also show that the de-mographics of the populationserved will likely affect thebaseline, and possibly the degreeof change. Of particular value, aspart of this project, the authorsimplemented and demonstratetheeffectivenessofatooldesignedto assess the impact of home-visiting programs targeting trigger abatement, which is  󿬂 exibleenough to apply to a somewhatheterogeneousgroupofprograms.This type of tool has the potentialto be very important in creatingneeded cross-program compari-sons, setting benchmarks of suc-cess, accumulating impact datato support intervention re-imbursement, and facilitating theimpact assessment of individualprograms. DRIVE CHANGE In a time when our healthsystem is increasingly focused onquality measures, value-basedcare incentive models, andquantitative impact assessment,well-designed tools, methods,and comparative values are keysto meaningful data and the as-similationofinformationthatcandrivechange.Thiskindofchangeis urgently needed by millionsof children across the countrywho struggle with uncontrolledasthma, and for whom educa-tional success, and even eco-nomic success, are at risk. Delaney Gracy, MD, MPH  ACKNOWLEDGMENTS I thank John Carlson, MD, PhD, assistantprofessor, Department of Pediatrics, Sec-tions of Allergy & Immunology andCommunityPediatricsandGlobalHealth,Tulane University School of Medicine,for his asthma expertise in preparing thiseditorial.IalsothankDennisWalto, CEOof Children ’ s Health Fund, for his insightand support. REFERENCES 1. Akinbami LJ, Simon AE, Rossen LM.Changing trends in asthma prevalenceamong children.  Pediatrics . 2016;137(1):e20152354.2. Nicholas SW, Jean-Louis B, Ortiz B,et al. Addressing the childhoodasthma crisis in Harlem: the HarlemChildren ’ s Zone Asthma Initiative.  Am J Public Health . 2005;95(2):245  –  249.3. Clark NM, Shah S, Dodge JA, ThomasLJ, Andridge RR, Little RJA. An evalu-ation of asthma interventions for preteenstudents.  J Sch Health . 2010;80(2):80  –  87.4. Asthma Disparities Working Group. TheCoordinatedFederalActionPlantoReduceRacial and Ethnic Asthma Disparities. USEnvironmental Protection Agency. 2012.Available at: https://www.epa.gov/asthma/coordinated-federal-action-plan-reduce-racial-and-ethnic-asthma-disparities.Accessed November 8, 2017.5. Gracy D, Fabian A, Roncaglione V,Savage K, Redlener I.  Health Barriers toLearning: The Prevalence and Educational Consequences in Disadvantaged Children .New York, NY: Children ’ s Health Fund;2017.6.  Guidelines for the Diagnosis and Manage-ment of Asthma: Expert Panel Report 3 (EPR 3) . Bethesda, MD: National Institutes of Health, National Heart, Lung, and BloodInstitute; 2007.7. CDC  ’ sNationalAsthmaControl Program: An Investment in America ’ s Health . Atlanta,GA: Centers for Disease Control andPrevention; 2013. AJPH  EDITORIALS 22  Editorial  Gracy   AJPH  January 2018, Vol 108, No. 1  C o p y r i g h t o f A m e r i c a n J o u r n a l o f P u b l i c H e a l t h i s t h e p r o p e r t y o f A m e r i c a n P u b l i c H e a l t h   A s s o c i a t i o n a n d i t s c o n t e n t m a y n o t b e c o p i e d o r e m a i l e d t o m u l t i p l e s i t e s o r p o s t e d t o a   l i s t s e r v w i t h o u t t h e c o p y r i g h t h o l d e r ' s e x p r e s s w r i t t e n p e r m i s s i o n . H o w e v e r , u s e r s m a y p r i n t ,  d o w n l o a d , o r e m a i l a r t i c l e s f o r i n d i v i d u a l u s e . 
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