The Economic Burden of Exposure to Secondhand Smoke for Child and Adult Never Smokers Residing in U.S. Public Housing

ObjectiveThe World Health Organization (WHO) reports that nonsmokers experience disease and death due to secondhand smoke (SHS) exposure in the home. We estimated the total excess burden and costs to society due to SHS exposure in U.S. public housing.MethodsWe quantified the public health burden for outcomes causally related to SHS exposure for nationally representative never-smoking residents in U.S. public housing using (1) WHO-recommended health outcomes and methodology, (2) publicly available and other large databases, and (3) published estimates of morbidity and mortality rates. We used published estimates of direct medical and nonmedical care costs and the value of productivity losses to estimate SHS-related societal costs for disease and death. We estimated the public health and economic burden for two serum cotinine limits of detection (LODs): 0.05 nanograms per milliliter (ng/mL) and 0.015 ng/mL.ResultsIn 2011, an estimated 37,791 never-smoking child and adult U.S. public housing residents experienced illness and death due to SHS exposure at home based on an LOD=0.05 ng/mL (50,967 residents at LOD=0.015 ng/mL). Costs incurred by society for these illnesses and deaths totaled $183 million (LOD=0.05 ng/mL) and $267 million (LOD=0.015 ng/mL) annually. Of the total costs, direct costs (medical and nonmedical) accounted for $128 million and $176 million for LOD=0.05 ng/mL and LOD=0.015 ng/mL, respectively. Medical care accounted for the majority of direct costs—$110 million at LOD=0.05 ng/mL and $153 million at LOD=0.015 ng/mL. Adverse respiratory health outcomes accounted for approximately one-half (56% at LOD=0.05 ng/mL and 52% at LOD=0.015 ng/mL) of total societal costs.ConclusionImplementing smoke-free policies in all U.S. public housing could save lives and decrease SHS-related morbidity and mortality in never-smoking residents, resulting in annual societal savings of $183 million at LOD=0.05 ng/mL and $267 million at LOD=0.015 ng/mL.An estimated 15%–18% of U.S. children are exposed to secondhand smoke (SHS) at home.¹ SHS is a major cause of disease, and there is no safe level of SHS exposure.^1,2 Children and nonsmoking adults living below the federal poverty level (FPL) are more likely to be exposed to SHS than those in higher socioeconomic status households.³ Children are especially vulnerable because their exposure patterns and developmental status enhance absorption of environmental toxicants.⁴ Additionally, because many elderly people with limited mobility live in public housing, they may spend more time indoors, be exposed to more SHS, and suffer more severe adverse health outcomes than the general population.² People with disabilities comprise nearly one-third of the public housing population and have greater SHS exposure than those without a disability.^5,6 Because SHS migrates, residents of multiunit housing who do not allow smoking in their home are at risk for SHS exposure if other residents in their building smoke.⁷ SHS migration has implications for nonsmoking public housing residents, as 88% of public housing is multiunit.⁸The World Health Organization (WHO) reports that there is sufficient evidence of causal relationships between SHS and adverse health outcomes, including lung cancer, heart disease, and asthma in adults; and low birthweight (LBW) (i.e., birthweight ≤2,500 grams), sudden infant death syndrome (SIDS), and lower respiratory infections (LRIs)—including respiratory syncytial virus, bronchitis, otitis media (OM), and asthma—in children.²Smoke-free policies significantly reduce adverse health outcomes caused by SHS.^9–13 In 2009 and 2012, the U.S. Department of Housing and Urban Development (HUD) encouraged public housing authorities to implement smoke-free policies in subsidized housing.^14,15 Recent research suggests that smoke-free policies are supported by a majority of never- and former-smoking subsidized housing residents and are associated with cessation or lower rates of smoking among smokers.^16,17 Recent data indicate that in 2013, more than 300 housing authorities had instituted smoke-free policies.^18,19The health and economic consequences of childhood SHS exposure in the United States are well documented,^20–28 but similar analyses are not available for nonsmoking adults. While there are published estimates of the U.S. public health burden associated with SHS exposure in adults and state-level economic studies on SHS that include nonsmoking adults, information on the national aggregate costs of SHS-related health effects in adults is sparse.^29–36A recent study estimated SHS-related costs in all government-subsidized housing using state-level estimates.³⁷ However, to our knowledge this is the first study to estimate the public health and economic burden of SHS in public housing based on nationally representative and other large-scale databases, including biomarker data. Quantifying the burden of SHS for residents may provide incentives to institute smoke-free policies in public housing.