Healthcare costs attributable to secondhand smoke exposure at home for U.S. adults

Healthcare utilisation and expenditures attributable to current e-cigarette use among US adults

AIMS

This study estimated annual healthcare expenditures attributable to current e-cigarette use among US adults, including current exclusive and dual/poly e-cigarette use.

METHODS

Analysing the 2015-2018 National Health Interview Survey data, we estimated the impacts of e-cigarette use on healthcare utilisation among adults aged 18+ years. Healthcare utilisation outcomes were hospital nights, emergency room (ER) visits, doctor visits and home visits. Current e-cigarette use was categorised as exclusive and dual/poly e-cigarette use. The econometric model included two equations: health status as a function of e-cigarette use and other independent variables, and healthcare utilisation as a function of health status, e-cigarette use, and other independent variables. Using an 'excess utilisation' approach, we multiplied the e-cigarette-attributable fraction derived from the model by annual health expenditures to calculate healthcare expenditures attributable to current exclusive and dual/poly e-cigarette use, the sum of which were expenditures attributable to all current e-cigarette use.

RESULTS

Current exclusive and dual/poly e-cigarette use, with 0.2% and 3.5% prevalence in 2015-2018, were associated with higher odds of reporting poor health status than never tobacco users. Poor health status was associated with higher odds of using the four healthcare services and a greater number of ER and doctor visits. Annual healthcare expenditures attributable to all current e-cigarette use was $15.1 billion ($2024 per user) in 2018, including $1.3 billion attributable to exclusive e-cigarette use ($1796 per user) and $13.8 billion attributable to dual/poly e-cigarette use ($2050 per user).

CONCLUSION

Adult current e-cigarette use was associated with substantial excess healthcare utilisation and expenditures.

Passive smoking as a risk factor among older adults: an ordered probability approach for Türkiye

Background/aim

Older adults represent a significant proportion of the population of many societies, and being one of the disadvantaged groups, they struggle with various difficulties in their social lives. Undoubtedly, passive smoking is one of these difficulties. Passive smoking among older adults, which is an important public health problem, is an issue that needs to be investigated. The aim of this study is to determine the relationship between the demographic and socio-economic characteristics of adults aged 60 and older in Türkiye and their exposure to secondhand smoke (SHS).

Methods

In this study, a microdata set of the 2016 and 2019 Turkey Health Survey conducted by the Turkish Statistical Institute (TUIK) was used. This survey was conducted by TUIK in the relevant years using a stratified sampling method to best represent the whole of Turkey. The study considered only demographic and socio-economic characteristics to investigate passive smoking. Since all the variables used in the study were categorical, the relationship between the dependent variable and the independent variables was first investigated using chi-square tests. In addition, since the dependent variable has an ordered-categorical probability form, the generalized ordinal logit model was used for the analysis of passive smoking and related factors.

Results

The rate of exposure to tobacco smoke of older adults who participated in the study in 2016 was 16%, while the rate of those who participated in the study in 2019 was 21%.

Conclusion

According to the findings of the study, older, uneducated, and uninsured smokers carry a more serious SHS risk. It may be beneficial for society for policy makers to carry out studies by considering these features a priority and focusing on policies in this context. Expanding smoke-free areas to cover older adult, increasing penalties as a deterrent, facilitating education, increasing state support for education, increasing education and public service announcements about tobacco harms, and facilitating social security are the main examples. This study's findings are crucial as a source of information for the development of policies and programs aimed at preventing the exposure of older adults to tobacco smoke.

Healthcare costs attributable to secondhand smoke exposure among Indian adults

INTRODUCTION

This paper estimates the direct economic costs of diseases attributable to secondhand smoking (SHS) in India for persons aged 15 years and above.

METHODS

Nationally representative data on health care expenditures, healthcare utilization, and SHS prevalence were used to estimate economic costs attributable to SHS. A prevalence-based attributable risk approach was used for estimating the attributable direct costs. To estimate the SHS-attributable fraction, the excess utilization of healthcare among SHS exposed non-smokers compared to unexposed non-smokers was estimated using a method of propensity score matching.

RESULTS

The annual direct economic costs attributable to SHS from all diseases in India in the year 2017 for persons aged 15+ years amounted to INR 566.7 billion (USD 8.7 billion). This amounted to INR 705 per adult non-smoker. The SHS attributable costs were higher among the youngest age group 20-24, and women bear 71% of the direct medical costs attributable to SHS.

CONCLUSIONS

The annual direct economic costs of SHS amount to approximately 0.33% of India's GDP, or 8.1% of total healthcare expenditures in India. It is also much larger than the total excise tax revenue from cigarettes and bidis. As bidi smoking is the most popular form of smoking in India and bidis are mostly consumed by the poor, a disproportionate burden of SHS is likely borne by poor households in India.

IMPLICATIONS

In India, 38.7% of adults are exposed to secondhand smoking (SHS) at home and 30.2% at work. However, there is no estimate of the economic burden of any kind from SHS exposure in India. This study used a prevalence-based attributable risk approach combined with a propensity score matching technique to estimate excess healthcare utilization for SHS exposed non-smokers and the annual direct economic costs of SHS in India. Annual direct SHS-attributable costs in India is INR 566.7 billion (USD 8.7 billion) SHS costs constituted 0.33% of GDP and 8.1% of healthcare expenditures in India.

Association between secondhand smoke and peripheral arterial disease: a meta-analysis of cross-sectional studies

PURPOSE

The association between secondhand smoke (SHS) and peripheral arterial disease (PAD) was inconsistent and the studies were relatively scarce, hence, we conducted a meta-analysis of the association between SHS and PAD.

MATERIALS AND METHODS

We systematically searched three electronic databases (PubMed, EMBASE, and Web of Science), and calculated the pooled prevalence risk ratio (RR) and estimated standard error by random effect model from the meta-analysis. Furthermore, we performed a subgroup meta-analysis according to the location of SHS exposure.

RESULTS

We initially identified 502 articles from the electronic database, and 6 articles, cross-sectional data from 4 cross-sectional studies and 2 prospective cohort studies, were included in the meta-analysis. Among these six articles, two studies showed a significant correlation between SHS exposure and PAD, whereas no study showed a negative correlation between SHS exposure and PAD. In the meta-analysis, pooled prevalence showed a significant association between SHS exposure and PAD (RR = 1.23; 95% confidence interval [CI] 1.08-1.41; z = 3.02, p = 0.003). In the subgroup analysis based on location of SHS exposure, the prevalence RR of PAD at home was 1.30 (95% CI 1.14-1.49, Z-3.99, p < 0.0001). The prevalence RR in the subgroup of SHS exposure at work was not significant (RR = 0.89; 95% CI 0.55-1.44; z = 0.48, p = 0.63).

CONCLUSION

Exposure to SHS was significantly and positively associated with PAD. Moreover, we found a significant association between exposure to SHS and PAD at home, but the association was not significant at work.

Secondhand Smoke Exposure Impairs Ion Channel Function and Contractility of Mesenteric Arteries

Cigarette smoke, including secondhand smoke (SHS), has significant detrimental vascular effects, but its effects on myogenic tone of small resistance arteries and the underlying mechanisms are understudied. Although it is apparent that SHS contributes to endothelial dysfunction, much less is known about how this toxicant alters arterial myocyte contraction, leading to alterations in myogenic tone. The study's goal is to determine the effects of SHS on mesenteric arterial myocyte contractility and excitability. C57BL/6J male mice were randomly assigned to either filtered air (FA) or SHS (6 h/d, 5 d/wk) exposed groups for a 4, 8, or 12-weeks period. Third and fourth-order mesenteric arteries and arterial myocytes were acutely isolated and evaluated with pressure myography and patch clamp electrophysiology, respectively. Myogenic tone was found to be elevated in mesenteric arteries from mice exposed to SHS for 12 wk but not for 4 or 8 wk. These results were correlated with an increase in L-type Ca2+ channel activity in mesenteric arterial myocytes after 12 wk of SHS exposure. Moreover, 12 wk SHS exposed arterial myocytes have reduced total potassium channel current density, which correlates with a depolarized membrane potential (Vm). These results suggest that SHS exposure induces alterations in key ionic conductances that modulate arterial myocyte contractility and myogenic tone. Thus, chronic exposure to an environmentally relevant concentration of SHS impairs mesenteric arterial myocyte electrophysiology and myogenic tone, which may contribute to increased blood pressure and risks of developing vascular complications due to passive exposure to cigarette smoke.

Asking the Right Questions About Secondhand Smoke

INTRODUCTION

Despite knowledge about major health effects of secondhand tobacco smoke (SHS) exposure, systematic incorporation of SHS screening and counseling in clinical settings has not occurred.

METHODS

A three-round modified Delphi Panel of tobacco control experts was convened to build consensus on the screening questions that should be asked and identify opportunities and barriers to SHS exposure screening and counseling. The panel considered four questions: (1) what questions should be asked about SHS exposure; (2) what are the top priorities to advance the goal of ensuring that these questions are asked; (3) what are the barriers to achieving these goals; and (4) how might these barriers be overcome. Each panel member submitted answers to the questions. Responses were summarized and successive rounds were reviewed by panel members for consolidation and prioritization.

RESULTS

Panelists agreed that both adults and children should be screened during clinical encounters by asking if they are exposed or have ever been exposed to smoke from any tobacco products in their usual environment. The panel found that consistent clinician training, quality measurement or other accountability, and policy and electronic health records interventions were needed to successfully implement consistent screening.

CONCLUSIONS

The panel successfully generated screening questions and identified priorities to improve SHS exposure screening. Policy interventions and stakeholder engagement are needed to overcome barriers to implementing effective SHS screening.

IMPLICATIONS

In a modified Delphi panel, tobacco control and clinical prevention experts agreed that all adults and children should be screened during clinical encounters by asking if they are exposed or have ever been exposed to smoke from tobacco products. Consistent training, accountability, and policy and electronic health records interventions are needed to implement consistent screening. Increasing SHS screening will have a significant impact on public health and costs.

Economic cost of tobacco smoking and secondhand smoke exposure at home in Thailand

IntroductionSmoking is an important public health concern. This study is the first that attempts to estimate the economic cost of smoking and secondhand smoke (SHS) exposure at home in Thailand.MethodA prevalence-based cost of illness approach following the guideline by WHO is employed.ResultIn 2017, the direct morbidity cost attributable to smoking and SHS exposure at home in Thailand was estimated to be at least US$265.97 million and US$23.66 million, respectively. Indirect morbidity costs from workday loss totalling US$25.04 million can be linked to smoking, while US$1.72 million was the result of SHS exposure at home. Smoking-attributable premature deaths resulted in an opportunity loss to the country equivalent to US$2.48 billion, while the figure was US$181.41 million for SHS exposure at home. Total years of life lost due to smoking and SHS-attributable premature deaths are estimated to have been at least 390 955 years for males and 82 536 years for females. The total economic cost from both types of tobacco exposure amounted to US$2.98 billion, equivalent to 17.41% of Thailand's current health expenditure or 0.65% of its gross domestic product in 2017.ConclusionSmoking imposed a substantial economic burden on Thailand in 2017. Seven per cent of this cost was imposed on non-smokers sharing a residence with smokers. Females bore 80% of this SHS-related cost. The findings call for prompt responses from public health agencies in Thailand to launch effective tobacco control policies.

Self-Reported Exposure to Secondhand Smoke and Support for Complete Smoking Bans in Multiunit Housing Among Smokers in the United States, Canada, and the United Kingdom

Introduction

Involuntary exposure to secondhand smoke most frequently occurs at home, which is problematic for residents of multiunit housing (MUH). The primary objective of this study was to estimate the extent of secondhand smoke incursions into the homes of MUH smokers who banned smoking in their homes but lived in buildings where smoking is allowed.

Methods

We used data from Wave 9 of the International Tobacco Control Four Country Survey. We estimated 1) the prevalence of complete smoking bans among smokers living in single-family homes vs MUH in the United States (n = 3,208), Canada (n = 1,592), and the United Kingdom (n = 1,403) from 2013 to 2015; 2) the extent of secondhand smoke incursions into the homes of MUH smokers who banned smoking in their units but lived in buildings that allow smoking; and 3) MUH smokers’ preferences for complete smoking bans in MUH. Weighted multivariable logistic regression estimated the country-specific adjusted prevalence of all outcomes.

Results

Overall, 53.0% of smokers living in single-family homes completely banned smoking in their homes, compared with 44.8% of smokers in MUH. Across all 3 countries, only 27.8% of MUH smokers reported that smoking was completely prohibited in their building. A similar percentage of MUH smokers who banned smoking in their home but lived in buildings allowing smoking reported a secondhand smoke incursion into their home in the United States (29.9%; 95% CI, 20.4%–41.5%), Canada (38.4%; 95% CI, 26.7%–51.6%), and the United Kingdom (24.7%; 95% CI, 15.7%–36.7%). Across all 3 countries, 36.1% (95% CI, 33.4%–38.9%) of smokers in MUH reported they preferred a complete smoking ban in all building areas.

Conclusion

A need remains to educate MUH operators and residents about the benefits of comprehensive smoke-free policies.

Burden of disease attributable to second-hand smoke exposure: A systematic review

Our aim was to provide a systematic review of studies on the burden of disease due to second-hand smoke (SHS) exposure, reviewing methods, exposure assessment, diseases causally linked to SHS, health outcomes, and estimates available to date. A literature review of studies on the burden of disease from SHS exposure, available in PubMed and SCOPUS, published 2007-2018 in English language, was carried out following the PRISMA recommendations. Overall, 588 studies were first identified, and 94 were eligible. Seventy-two studies were included in the systematic review. Most of them were based on the comparative risk assessment approach, assessing SHS exposure using mainly surveys on exposure at home/workplaces. Diseases more frequently studied were: lung cancer, ischemic heart disease, stroke, chronic obstructive pulmonary disease, asthma and breast cancer in adults; lower respiratory tract infection, otitis media, asthma, sudden infant death syndrome and low birth weight in children. The SHS exposure assessment and the reported population attributable fractions (PAF) were largely heterogeneous. As an example, the PAF from lung cancer varied between 0.6% and 20.5%. Moreover, PAF were estimated applying relative risks and SHS exposures with no consistent definitions or with different age classes. The research gap on the SHS exposure burden is shrinking. However, estimates are not yet available for a number of countries, particularly the Middle Eastern and African countries, and not all diseases with the strongest evidence of causation, such as sudden infant death syndrome, have been explored. Moreover, in some cases the applied methodology revealed relatively low quality of data.

Exposure to Secondhand Tobacco Smoke at Airport Terminals

Background

Airports may represent significant sources of secondhand smoke (SHS) exposure for both travelers and employees. While previously common smoking rooms have largely disappeared from US airports, smoking continues to occur outdoors at terminal entrances. SHS may be especially high at arrival areas, since they oftentimes are partially enclosed by overhead departures, creating stagnant microenvironments. This study assessed particulate matter <2.5 microns in diameter (PM2.5), a common surrogate for SHS, at airport terminal locations to evaluate both outdoor exposure risk and possible indoor drift of SHS from outdoor sources.

Methods

A convenience sample of nine airport terminal arrival areas in the US state of Florida was surveyed between February and July 2018. PM2.5 levels were assessed outdoors and indoors at terminal entrances and at control areas far into terminal interiors. We also examined the impact of smoking location on SHS exposure by correlating cigarette and passing vehicle counts with PM2.5 levels at terminals with contrasting proximity of designated smoking locations to terminal entrances.

Results

Although outdoor PM2.5 levels (mean 17.9, SD 6.1 µg/m³) were significantly higher than indoors (p < 0.001), there was no difference between indoor areas directly inside terminal entrances and areas much further interior (mean 8.8, SD 2.6 vs mean 8.5, SD 3.0 µg/m³, p=0.49). However, when smoking areas were in close proximity to terminal entrances, the number of lit cigarettes and vehicular traffic per minute predicted 70% of the variance of PM2.5 levels (p < 0.001), which was attributable mostly to the cigarette number (β = 0.83; 95% CI (0.55 to 1.11); p < 0.001). This effect was not observed at smoking areas further away.

Conclusion

PM2.5 data did not suggest indoor drift from outside smoking. Nevertheless, absolute exposure outdoors was high and correlated with the location of designated smoking areas. Further studies are needed to examine the effect of microclimate formation on exposure risk.

Healthcare Costs of Secondhand Smoke Exposure at Home for U.S. Children

INTRODUCTION

The purpose of this study is to estimate healthcare utilization and healthcare costs due to secondhand smoke exposure at home for children in the U.S.

METHODS

Using data from the 2000, 2005, and 2010 U.S. National Health Interview Surveys, the authors analyzed the association between secondhand smoke exposure at home and utilization of three types of healthcare services (hospital nights, emergency room visits, and doctor visits) for children aged 3-14 years (N=16,860). A zero-inflated Poisson regression model was used to control for sociodemographic characteristics and the number of months without health insurance. The authors determined excess healthcare utilization attributable to secondhand smoke exposure at home for children and then estimated annual secondhand smoke-attributable healthcare costs as the product of annual excess healthcare utilization and unit costs obtained from the 2014 Medical Expenditures Panel Survey. This study was conducted from 2016 to 2018.

RESULTS

The prevalence of secondhand smoke exposure at home for children in 2000, 2005, and 2010 was 25.0%, 12.3%, and 9.1%, respectively. Secondhand smoke exposure at home was positively associated with emergency room visits, but was not significantly associated with nights at the hospital or doctor visits for children. Secondhand smoke exposure at home for children resulted in an excess of 347,156 emergency room visits in 2000, 124,412 visits in 2005, and 101,570 visits in 2010, which amounted to $215.1 million, $77.1 million, and $62.9 million in excess annual healthcare costs (2014 dollars) in 2000, 2005, and 2010, respectively.

CONCLUSIONS

Although U.S. healthcare costs attributable to secondhand smoke exposure at home for children are declining, interventions to reduce secondhand smoke exposure at home for children are still needed to reduce the economic burden attributable to secondhand smoke exposure.