The Public Health and Economic
Burdens of Secondhand Smoke
(SHS) Exposures of NeverSmoking Public Housing Residents
Jacquelyn Mason, PhD
National Healthy Homes Conference
May 29, 2014
National Center for Environmental Health
Division of Emergency and Environmental Health Services
Background




SHS is a major cause of
disease1
There is no safe level of SHS2
A lower SES is associated
with a higher smoking
prevalence3
Several populations are
especially vulnerable to SHS
exposure
 Children2
 Elderly2
 Disabled4
1U.S.
Department of Health and Human Services (2006).
M, Jaakkola MS, Prüss-Üstün A, Schweizer C, Woodward A. (2010).
3Barbeau, E. M., N. Krieger, et al. (2004).
4Hall AB, Schumacher JR, Cannell MB, Berry JB, Schiaffino M, Park S. (2013).
2Öberg
Background

Secondhand smoke can migrate between units in
multi-unit housing
 Cotinine levels1
 Air transfer2
 Measured environmental
nicotine3
 Tobacco odor3

88% of public housing is
multi-unit4
1Wilson
et al. (2011).
B. A., M. J. Travers, et al. (2010).
3Kraev, T. A., G. Adamkiewicz, et al. (2009).
4U.S. Department of Housing and Urban Development (2008).
2King,
Background


HUD policy recommendations1,2
Smoke-free policy benefits:
 Improved health
 Lower expenditures
• Health-related
• Fewer fires
• Property-related
1U.S.
2U.S.
Department of Housing and Urban Development. Non-smoking policies in public housing (2009).
Department of Housing and Urban Development. Non-smoking policies in public housing (2012).
Study Objectives and Approach

Objective
 Estimate the public health and economic
burdens associated with SHS exposures among
never smokers in public housing

Approach
 Estimating the public health burden
• Utilized methodology and health outcomes from
the World Health Organization (WHO) report
• Obtained published data from existing
databases and the literature
• Performed analysis for two blood cotinine limits
of detection (LODs) = 0.015 and 0.05 ng/dL
 Estimating the economic burden
• Used a Cost-of-illness approach
• Obtained published data from existing
databases and the literature
Basis for Methods Used

WHO Report on SHS (2010)1
 Based on reviews and metaanalyses of literature
 Presents causal health outcomes
 Proposes methodology for
estimating SHS-attributable
burden
1Öberg
M, Jaakkola MS, Prüss-Üstün A, Schweizer C, Woodward A. (2010).
Summary of Health Outcomes Causallyrelated to SHS Exposure from WHO1
Adults
Lung cancer
Ischaemic heart disease (IHD)
Asthma (onset)
Asthma (exacerbation/severity)
Chronic obstructive pulmonary disease (COPD)
Breast cancer
Stroke
+ = sufficient evidence of a causal relationship
 = suggestive evidence of an association
1Öberg
M, Jaakkola MS, Prüss-Üstün A, Schweizer C, Woodward A. (2010).
+
+
+




Summary of Health Outcomes Causallyrelated to SHS Exposure from WHO1
Infants and Children
Low birth weight (LBW)
Sudden Infant Death Syndrome (SIDS)
Lower respiratory infections (LRI)
Otitis media (OM) (acute and/or recurrent)
Asthma (onset)
Preterm delivery
+ = sufficient evidence of a causal relationship
 = suggestive evidence of an association
1Öberg
M, Jaakkola MS, Prüss-Üstün A, Schweizer C, Woodward A. (2010).
+
+
+
+
+

Relative Risks due to SHS exposure from
the WHO Report (2010)1
Health Condition
Relative Risk
Lung Cancer
Adults Ischemic Heart Disease
Asthma
Low Birth Weight
Sudden Infant Death Syndrome
Children Lower Respiratory Infection
Otitis Media
Asthma
1.21
1.27
1.97
1.38
1.94
1.55
1.66
1.32
1Öberg
M, Jaakkola MS, Prüss-Üstün A, Schweizer C, Woodward A. (2010).
Methods: Populations and Data Sources
Used to Estimate the Public Health Burden
Never
Smokers1
Exposed to
SHS2
Public
Housing
Population3
1Estimates
Study population: Adult
never smokers who live in
public housing and are
exposed to SHS
of never smokers in the population were made using NHIS among households receiving gov’t housing assistance and
income ≤ 200% of poverty level
2Estimated Proportion of never smoking population who are exposed to SHS were made using NHANES among income ≤1.3 times
poverty level
3Supplied by the Department of Housing and Urban Development; extracted from the Public and Indian Housing Database
Methods: WHO Methodology for
Estimating the Public Health Burden1
1.
2.
3.
4.
Collect health statistics (e.g. disease incidence,
mortality rate, DALYs)
Assess SHS exposure prevalence
Estimate disease burden among non-smokers (neversmokers)
Compute population attributable fraction (PAF)
𝑷𝑨𝑭 =
𝒑 𝑹𝑹−𝟏
𝒑 𝑹𝑹−𝟏 +𝟏
where
p = proportion exposed to SHS
RR = relative risk for health outcome
5.
Calculate attributable burdens
1Öberg
M, Jaakkola MS, Prüss-Üstün A, Schweizer C, Woodward A. (2010).
Methods: Drivers for Estimating
the Economic Burden

Societal perspective
 All costs
 All payers

Incremental/excess costs
= with health condition – without health condition

Human capital approach:
Productivity losses due to lost wages

2011 dollars
 Healthcare – Personal Consumption Expenditures
Price Index
 Productivity – Consumer Price Index
Methods: Costs Included in
Estimating the Economic Burden
Direct Medical
Direct Nonmedical
Physician
Visits
Medications
Outpatient
Care
Labs
Travel
Paid
Childcare
Societal Perspective
Productivity:
Mortality
Productivity:
Morbidity
Work
Absences
Missed
Schooldays
Total Productivity
Present
Value of
Lost
Earnings
Cost Data Sources by Health Outcome from
WHO Report1
Health Outcome
Lung Cancer Morbidity
Lung Cancer Mortality
Adults IHD Morbidity
IHD Mortality
Asthma Morbidity and Mortality
LBW Morbidity
LBW Mortality
SIDS
Children
LRI
OM
Asthma Morbidity and Mortality
1Öberg
Author(s), Publication Date
Chang et al., 2004
Bradley et al., 2008
Trogdon, 2011 (personal communication)
Rogers et al., 2011
Barnet and Nurmagambetov, 2010
Institute of Medicine, 2007
Based on Grosse et al. 2009
Based on Grosse et al., 2009
Shi et al., 2011; Leader et al., 2003
Soni, 2008; Alsarraf et al., 1999
Barnet and Nurmagambetov, 2010
M, Jaakkola MS, Prüss-Üstün A, Schweizer C, Woodward A. (2010).
Preliminary Results:
Annual Estimated Public Health and Economic
Burdens (Blood Cotinine LOD = 0.05 ng/mL)
Adults
SHS-attributable
Number with
Productivity
Health Condition Health Condition Direct Medical
Losses
Lung Cancer
19
$947,696 $2,078,214
IHD
286
$1,445,414 $21,613,294
Asthma
16,409
$55,331,463 $7,538,019
Total
16,714
$57,724,573 $31,229,527
Total
$3,025,910
$23,058,708
$62,869,482
$88,954,100
Children
SHS-attributable
Number with
Health Condition Health Condition Direct Medical
$20,984,613
LBW
507
SIDS
11
-LRI
380
$2,873,486
OM
10439
$4,012,085
Asthma
10972
$37,006,816
Total
22309
$64,876,999
Productivity
Losses
Total
$17,077,410 $38,062,023
$13,860,975 $13,860,975
$1,036,598 $3,910,084
$16,976,841 $20,988,926
$1,056,040 $38,062,856
$50,007,863 $114,884,862
Preliminary Results:
Annual Estimated Public Health and
Economic Burdens by LOD1
Number with
Health Condition
Adults
16,714
Children
22,309
39,023
LOD = 0.05 ng/mL
Productivity
Direct Medical
Losses
Total Costs
$57,724,573
$31,229,527
$88,954,100
$64,876,999
$50,007,863 $114,884,862
$122,601,572
$81,237,390 $203,838,963
Number with
Health Condition
Adults
23,706
Children
29,223
52,929
LOD = 0.015 ng/mL
Productivity
Direct Medical
Losses
Total Costs
$82,346,604
$53,106,084 $135,452,688
$90,972,407
$71,902,381 $162,874,788
$173,319,011 $125,008,465 $298,327,476
1Blood cotinine
LOD
Comparison with a Recent Study:
Costs Included and SHS-exposure
Classification Method
Cost type/other
King BA, Peck RM, Babb SD. (2013).
Our study
King et al.
(2013)
Comparison with a Recent Study: Results
Our study1
($ millions)2
King et al. (2013)3
($ millions)
Healthcare
123
101 (50-181)
Productivity
81
N/A
Unit renovation
N/A
32 (18-50)
Smoking-attributable
fires
N/A
21 (12-33)
Total
204
154 (80-265)
Cost type
1LOD
= 0.05 ng/dL
2011 dollars
3King BA, Peck RM, Babb SD. (2013).
2In
Limitations






National disease/death rates and cost estimates may
not be applicable to public housing residents
Assumed RR for morbidity = RR for mortality, which
may not be a valid assumption
Included all never smokers who met our criteria
regardless of where their SHS exposure occurred
Blood cotinine levels reflect only recent exposures to
cigarette smoke
All societal costs not accounted for
Did not include former and current smokers
Conclusions

The public health and economic burden
associated with SHS exposures in public
housing is significant.

Implementation of a smoke-free policy in
all U.S. public housing can help improve
the health of public housing residents and
reduce societal including medical costs.
Co-Authors

William Wheeler, MPH
CDC/NCCDPHP

Mary Jean Brown, ScD, Rn
CDC/NCEH
Acknowledgements

Stephen Babb, MPH and Brian King, PhD
CDC, NCCDPHP, Office of Smoking and Health

Lydia Taghavi, AB
U.S. Department of Housing and Urban Development, Office of Policy
Development and Research

Peter Ashley, DPH1; Alastair McFarlane ‡ , PhD;
and Barry Steffen2, MS
1U.S. Department
of Housing and Urban Development, Office of Healthy
Homes and Lead Hazard Control/2Office of Policy Development and
Research

Turnsynbek Nurmagambetov, PhD
CDC, NCEH, Air Pollution and Respiratory Branch

Scott Grosse, PhD
CDC, NCBDDD, Office of the Director
References

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Barbeau, E. M., N. Krieger, et al. (2004). "Working class matters: socioeconomic disadvantage, race/ethnicity,
gender, and smoking in NHIS 2000." Am J Public Health 94(2): 269-278.
U.S. Department of Health and Human Services (2006). The Health Consequences of Involuntary Exposure
to Tobacco Smoke: A Report of the Surgeon General. U.S. Department of Health and Human Services,
National Center for Chronic Disease Prevention, Office on Smoking and Health. Atlanta, GA.
Jaakkola, M. S. (2002). "Environmental tobacco smoke and health in the elderly." Eur Respir J 19(1): 172-181.
Kraev, T. A., G. Adamkiewicz, et al. (2009). "Indoor concentrations of nicotine in low-income, multi-unit
housing: associations with smoking behaviours and housing characteristics." Tob Control 18(6): 438-444.
U.S. Department of Housing and Urban Development. Non-smoking policies in public housing. In: U.S.
Department of Housing and Urban Development , Office of Healthy Homes and Lead Hazard Control, editor.;
2009.
U.S. Department of Housing and Urban Development. Non-smoking policies in public housing. In: U.S.
Department of Housing and Urban Development, Office of Healthy Homes and Lead Hazard Control, editor.;
2012.
King, B. A., M. J. Travers, et al. (2010). "Secondhand smoke transfer in multiunit housing." Nicotine Tob Res
12(11): 1133-1141.
U.S. Department of Housing and Urban Development (2008). Characteristics of HUD-assisted renters and
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Kamble, S. and M. Bharmal (2009). "Incremental direct expenditure of treating asthma in the United States."
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King BA, Peck RM, Babb SD. Cost savings associated with prohibiting smoking in U.S. subsidized housing.
Am J Prev Med 2013;44(6):631-4.
References:
Source Articles for Cost Data
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Chang S, Long SR, Kutikova L, Bowman L, Finley D, Crown WH, et al. Estimating the cost of cancer: results on the basis of
claims data analyses for cancer patients diagnosed with seven types of cancer during 1999 to 2000. J Clin Oncol
2004;22(17):3524-30.
Bradley CJ, Yabroff KR, Dahman B, Feuer EJ, Mariotto A, Brown ML. Productivity costs of cancer mortality in the United
States: 2000-2020. J Natl Cancer Inst 2008 Dec;100(24):1763-70.
Roger VL, Go AS, Lloyd-Jones DM, Adams RJ, Berry JD, Brown TM, et al. Heart disease and stroke statistics--2011 update:
a report from the American Heart Association. Circulation 2011;123(4):e18-e209.
Barnett SB, Nurmagambetov TA. Costs of asthma in the United States: 2002-2007. J Allergy Clin Immunol
2011;127(1):145-52.
U.S. IOM Committee on Understanding Premature Birth and Assuring Healthy Outcomes. Preterm birth: causes,
consequences, and prevention. Washington DC: National Academy of Sciences; 2007.
Grosse SD, Krueger KV, Mvundura M. Economic productivity by age and sex: 2007 estimates for the United States. Med
Care 2009;47(7 Suppl 1):S94-103.
Shi N, Palmer L, Chu BC, Katkin JP, Hall CB, Masaquel AS, et al. Association of RSV lower respiratory tract infection and
subsequent healthcare use and costs: a Medicaid claims analysis in early-preterm, late-preterm, and full-term infants. J
Med Econ 2011;14(3):335-40.
Leader S, Yang H, DeVincenzo J, Jacobson P, Marcin JP, Murray DL. Time and out-of-pocket costs associated with
respiratory syncytial virus hospitalization of infants. Value Health 2003;6(2):100-6.
Soni A. Ear infections (otitis media) in children (0-17): use and expenditures, 2006, Statistical Brief #228. Rockville, MD:
Agency for Healthcare Research and Quality 2008.
Alsarraf R, Jung CJ, Perkins J, Crowley C, Alsarraf NW, Gates GA. Measuring the indirect and direct costs of acute otitis
media. Arch Otolaryngol Head Neck Surg 1999;125(1):12-8.
Questions
My contact information:
Jacquelyn Mason, PhD
Email address: zao4@cdc.gov
For more information please contact Centers for Disease Control and Prevention
1600 Clifton Road NE, Atlanta, GA 30333
Telephone: 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348
E-mail: cdcinfo@cdc.gov Web: http://www.cdc.gov
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the
Centers for Disease Control and Prevention.
National Center for Environmental Health
Division of Emergency and Environmental Health Services