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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 Health. Division of Emergency and Environmental Health Services. National Healthy Homes Conference May 29, 2014.

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Jacquelyn Mason, PhD

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  1. The Public Health and Economic Burdens of Secondhand Smoke (SHS) Exposures of Never-Smoking Public Housing Residents Jacquelyn Mason, PhD National Center for Environmental Health Division of Emergency and Environmental Health Services National Healthy Homes Conference May 29, 2014

  2. 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).

  3. 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).

  4. 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).

  5. 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

  6. 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).

  7. Summary of Health Outcomes Causally-related to SHS Exposure from WHO1 + = sufficient evidence of a causal relationship  = suggestive evidence of an association 1Öberg M, Jaakkola MS, Prüss-Üstün A, Schweizer C, Woodward A. (2010).

  8. Summary of Health Outcomes Causally-related to SHS Exposure from WHO1 + = sufficient evidence of a causal relationship  = suggestive evidence of an association 1Öberg M, Jaakkola MS, Prüss-Üstün A, Schweizer C, Woodward A. (2010).

  9. Relative Risks due to SHS exposure from the WHO Report (2010)1 1Öberg M, Jaakkola MS, Prüss-Üstün A, Schweizer C, Woodward A. (2010).

  10. Methods: Populations and Data Sources Used to Estimate the Public Health Burden • Exposed to SHS2 • Never Smokers1 • Public • Housing • Population3 Study population: Adult never smokers who live in public housing and are exposed to SHS 1Estimates 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

  11. Methods: WHO Methodology for Estimating the Public Health Burden1 • Collect health statistics (e.g. disease incidence, mortality rate, DALYs) • Assess SHS exposure prevalence • Estimate disease burden among non-smokers (never-smokers) • Compute population attributable fraction (PAF) wherep = proportion exposed to SHS RR = relative risk for health outcome • Calculate attributable burdens 1Öberg M, Jaakkola MS, Prüss-Üstün A, Schweizer C, Woodward A. (2010).

  12. 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

  13. Direct Medical Direct Nonmedical Methods: Costs Included in Estimating the Economic Burden Travel Paid Childcare Physician Visits Medications Outpatient Care Labs Societal Perspective Productivity: Mortality Productivity: Morbidity Work Absences Missed Schooldays Present Value of Lost Earnings Total Productivity

  14. Cost Data Sources by Health Outcome from WHO Report1 1Öberg M, Jaakkola MS, Prüss-Üstün A, Schweizer C, Woodward A. (2010).

  15. Preliminary Results: Annual Estimated Public Health and Economic Burdens (Blood Cotinine LOD = 0.05 ng/mL)

  16. Preliminary Results: Annual Estimated Public Health andEconomic Burdens by LOD1 1Blood cotinine LOD

  17. Comparison with a Recent Study: Costs Included and SHS-exposure Classification Method King BA, Peck RM, Babb SD. (2013).

  18. Comparison with a Recent Study: Results 1LOD = 0.05 ng/dL 2In 2011dollars 3King BA, Peck RM, Babb SD. (2013).

  19. 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

  20. 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.

  21. Co-Authors • William Wheeler, MPHCDC/NCCDPHP • Mary Jean Brown, ScD, Rn CDC/NCEH

  22. Acknowledgements • Stephen Babb, MPH and Brian King, PhDCDC, NCCDPHP, Office of Smoking and Health • Lydia Taghavi, ABU.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

  23. 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.

  24. 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.

  25. Questions 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. My contact information: Jacquelyn Mason, PhD Email address: zao4@cdc.gov National Center for Environmental Health Division of Emergency and Environmental Health Services

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