The Public Health and Economic Burdens of Secondhand Smoke (SHS) Exposures of Never- Smoking Public Housing Residents Jacquelyn Mason, PhD National Center.
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The Public Health and Economic Burdens of
Secondhand Smoke (SHS) Exposures of Never-
Smoking Public Housing Residents
Jacquelyn Mason, PhD
National Center for Environmental HealthDivision of Emergency and Environmental Health Services
National Healthy Homes ConferenceMay 29, 2014
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). 2Öberg 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).
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).2King, 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).
Background
HUD policy recommendations1,2
Smoke-free policy benefits: Improved health Lower expenditures
• Health-related• Fewer fires• Property-related
1U.S. Department of Housing and Urban Development. Non-smoking policies in public housing (2009).2U.S. 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 meta-analyses 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 Causally-related to SHS Exposure
from WHO1
1Öberg M, Jaakkola MS, Prüss-Üstün A, Schweizer C, Woodward A. (2010).
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
Summary of Health Outcomes Causally-related to SHS Exposure
from WHO1
1Öberg M, Jaakkola MS, Prüss-Üstün A, Schweizer C, Woodward A. (2010).
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
Relative Risks due to SHS exposure from the WHO Report
(2010)1
Health ConditionRelative
Risk
Adults Lung Cancer 1.21 Ischemic Heart Disease 1.27 Asthma 1.97
Children
Low Birth Weight 1.38 Sudden Infant Death Syndrome 1.94 Lower Respiratory Infection 1.55
Otitis Media 1.66 Asthma 1.32
1Öberg M, Jaakkola MS, Prüss-Üstün A, Schweizer C, Woodward A. (2010).
PublicHousingPopulation3
Never Smokers1
Exposed to SHS2
Study population: Adult never smokers who live in public housing and are exposed to SHS
Methods: Populations and Data Sources Used to Estimate the
Public Health Burden
1Estimates of never smokers in the population were made using NHIS among households receiving gov’t housing assistance and income ≤ 200% of poverty level2Estimated Proportion of never smoking population who are exposed to SHS were made using NHANES among income ≤1.3 times poverty level3Supplied 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. Collect health statistics (e.g. disease incidence, mortality rate, DALYs)
2. Assess SHS exposure prevalence3. Estimate disease burden among non-
smokers (never-smokers)4. Compute population attributable fraction
(PAF) 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 Estimatingthe 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
Physician Visits
Medications
Outpatient CareLabs
Present Value of
Lost Earnings
TravelPaid
Childcare
Work Absences
Missed Schoolday
s
Societal Perspective
Direct Medical
Productivity:Morbidity
Productivity:Mortality
Direct Nonmedical
Total Productivity
Cost Data Sources by Health Outcome from WHO Report1
1Öberg M, Jaakkola MS, Prüss-Üstün A, Schweizer C, Woodward A. (2010).
Health Outcome Author(s), Publication Date
Adults
Lung Cancer Morbidity Chang et al., 2004 Lung Cancer Mortality Bradley et al., 2008
IHD MorbidityTrogdon, 2011 (personal communication)
IHD Mortality Rogers et al., 2011 Asthma Morbidity and Mortality
Barnet and Nurmagambetov, 2010
Children
LBW Morbidity Institute of Medicine, 2007 LBW Mortality Based on Grosse et al. 2009 SIDS Based on Grosse et al., 2009 LRI Shi et al., 2011; Leader et al., 2003 OM Soni, 2008; Alsarraf et al., 1999 Asthma Morbidity and Mortality
Barnet and Nurmagambetov, 2010
Preliminary Results: Annual Estimated Public Health and
Economic Burdens (Blood Cotinine LOD = 0.05 ng/mL)
AdultsSHS-
attributable Health
Condition
Number with Health
Condition
Direct
Medical
Productivit
y Losses Total Lung Cancer 19 $947,696 $2,078,214 $3,025,910
IHD 286 $1,445,414$21,613,29
4 $23,058,708Asthma 16,409 $55,331,463 $7,538,019 $62,869,482
Total 16,714 $57,724,573$31,229,52
7 $88,954,100
ChildrenSHS-
attributable Health
Condition
Number with Health
Condition
Direct
Medical
Productivity
Losses Total
LBW 507 $20,984,613$17,077,41
0$38,062,02
3
SIDS 11 --$13,860,97
5$13,860,97
5 LRI 380 $2,873,486 $1,036,598 $3,910,084
OM 10439 $4,012,085$16,976,84
1$20,988,92
6
Asthma 10972 $37,006,816 $1,056,040$38,062,85
6
Total 22309 $64,876,999$50,007,86
3$114,884,8
62
Preliminary Results: Annual Estimated Public Health and
Economic Burdens by LOD1
LOD = 0.05 ng/mLNumber with
Health Condition
Direct
MedicalProductivity
Losses Total CostsAdults 16,714 $57,724,573 $31,229,527 $88,954,100
Children 22,309 $64,876,999 $50,007,863
$114,884,862
39,023$122,601,57
2 $81,237,390$203,838,96
3LOD = 0.015 ng/mLNumber with
Health Condition
Direct
MedicalProductivity
Losses Total Costs
Adults 23,706 $82,346,604 $53,106,084$135,452,68
8Childre
n 29,223 $90,972,407 $71,902,381$162,874,78
8
52,929$173,319,01
1$125,008,46
5$298,327,47
61Blood cotinine LOD
Comparison with a Recent Study: Costs Included and SHS-exposure
Classification Method
King BA, Peck RM, Babb SD. (2013).
Cost type/other
Our studyKing et
al. (2013)
Direct medical Direct non-medical
Productivity losses
Fires Apartment renovation
SHS-exposure classification method
Cotinine biomarker data• LOD = 0.015
ng/dL• LOD = 0.05 ng/dL
Self-report
Comparison with a Recent Study: Results
Cost typeOur study1 ($ 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)
1LOD = 0.05 ng/dL2In 2011 dollars3King BA, Peck RM, Babb SD. (2013).
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 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 their units in 2003.
Kamble, S. and M. Bharmal (2009). "Incremental direct expenditure of treating asthma in the United States." J Asthma 46(1): 73-80.
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
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
For more information please contact Centers for Disease Control and Prevention1600 Clifton Road NE, Atlanta, GA 30333Telephone: 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348E-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 HealthDivision of Emergency and Environmental Health Services
My contact information:Jacquelyn Mason, PhDEmail address: zao4@cdc.gov
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