Jacquelyn Mason, PhD

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


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


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


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 outcome5. Calculate attributable burdens


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


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) Adults

SHS-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 study

King 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 type Our study1 ($ millions)2

King et al. (2013)3

($ millions)Healthcare 123 101 (50-181)Productivity 81 N/AUnit 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: [email protected] 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: [email protected]

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Jacquelyn Mason, PhD