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Your Environment. Your Health.

The economic impact of exposure to secondhand smoke in Minnesota

Environmental Health Economic Analysis Annotated Bibliography


Research article Cost analysis (CA)
Waters HR, Foldes SS, Alesci NL and Samet J
American Journal of Public Health
This cost analysis study estimated the prevalence and costs of treated medical conditions related to secondhand smoke exposure (e.g., lung cancer and coronary heart disease) in Minnesota and found that the total annual cost of treatment was $228.7 million. The results presented a strong rationale for regulating smoking in public places and were used to support the passage of Minnesota's Freedom to Breathe Act of 2007.
Nonsmokers — children and adolescents (≤ 17 years); adults (18 years +)

Health Outcomes

  • Birth outcomes (low birth weight)
  • respiratory outcomes (acute lower respiratory illnesses, asthma)
  • ear infection
  • cancer outcomes (lung cancer)
  • cardiovascular outcomes (coronary heart disease)

Environmental Agents

List of Environmental Agents:

  • Air pollutants (tobacco smoke)

Source of Environmental Agents:

  • Cigarette smoke (secondhand)

Economic Evaluation / Methods and Source


  • Cost analysis (CA)

Cost Measured:

  • Costs related to professional services
  • inpatient/outpatient hospital services
  • laboratory, radiology, and pathology services
  • costs of prescribed pharmaceuticals for all assessed outcomes

Potential Cost Measures:

  • Medical costs related to sub conditions such as "cough, phlegm, wheeze, and breathlessness among schoolchildren" and "lower level of lung function during childhood" were excluded because they could not be clearly mapped to coded medical conditions with administrative claims data. Medical costs related to SIDS were excluded because the condition leads to immediate mortality instead of treatment. Investigators also excluded costs associated with health conditions the surgeon general identified as having a "suggestive but not sufficient" causal link with exposure to secondhand smoke.

Benefits Measures: (Not available)

Potential Benefits: (Not available)


  • Minnesota

Models Used:

  • Population Attributable Risk (PAR) equation
  • Episode Treatment Group methodology (ETG codes)

Methods Used:

  • The authors estimated medical treatment costs related to exposure to secondhand tobacco smoke (SHS) in the state of Minnesota. To generate prevalence and cost estimates, the authors — 1) identified health conditions caused by secondhand smoke exposure; 2) determined the prevalence for each condition for Blue Cross members; 3) adjusted the treated prevalence to the state level; 4) determined the number of episodes attributable to secondhand smoke; and 5) determined the cost per episode. The authors used Episode Treatment Group (ETG) codes, applied to administrative claims data from Blue Cross, to identify individuals with an episode, and the average cost per episode, for each of the assessed health conditions for the year 2003.

Sources Used:

  • Administrative claims data (Blue Cross Blue Shield of Minnesota); The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General (2006); Current Population Survey (Bureau of Labor Statistics, 2004); Health Insurance Coverage in Minnesota: Trends from 2001-2004 (Minnesota Health Access Survey, 2006); Minnesota Department of Health (2006); Agency for Health Care Research and Quality Procedures in US Hospitals (2003); Minnesota Department of Human Services; Medicare Chart Book (2006); American Cancer Society (2006); Medical Expenditure Panel Survey (MEPS) (2003); US Consumer Price Index for Medical Services (US Department of Labor, 2006); additional sources cited in publication

Economic Evaluation / Methods and Source


  • Waters HR, Foldes SS, Alesci NL and Samet J. 2009. The economic impact of exposure to secondhand smoke in Minnesota. American Journal of Public Health.
  • Pubmed
  • DOI

NIEHS Funding: (Not available)

Other Funding: (Not available)

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