摘要：Objectives. Using the risk categories established by the 2006 US surgeon general's report, we estimated medical treatment costs related to exposure to secondhand tobacco smoke (SHS) in the state of Minnesota. Methods. We estimated the prevalence and costs of treated medical conditions related to SHS exposure in 2003 with data from Blue Cross and Blue Shield (Minnesota's largest insurer), the Current Population Survey, and population attributable risk estimates for these conditions reported in the scientific literature. We adjusted treatment costs to the state level by health insurance category by using the Medical Expenditure Panel Survey. Results. The total annual cost of treatment in Minnesota for conditions for which the 2006 surgeon general's report found sufficient evidence to conclude a causal link with exposure to SHS was $228.7 million in 2008 dollars—equivalent to $44.58 per Minnesota resident. Sensitivity analyses showed a range from $152.1 million to $330.0 million. Conclusions. The results present 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. In introductory remarks during the press conference to launch the 2006 report, Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General , 1 Surgeon General Richard Carmona stated that “the debate is over. The science is clear: secondhand smoke is not a mere annoyance, but a serious health hazard that causes premature death and disease in children and nonsmoking adults.” 2 That report brought into public focus the epidemiological and medical evidence that has been accumulating rapidly in recent years about the dangers of secondhand tobacco smoke (SHS)—also known as environmental tobacco smoke, passive smoking, and involuntary smoking. Knowledge about these dangers has advanced rapidly since the 1972 surgeon general's report first considered the health risks of SHS. 3 – 5 The 1986 surgeon general's report, The Health Consequences of Involuntary Smoking , found evidence that exposure to SHS is linked to important medical conditions—including coronary heart disease, heart attacks, and chronic respiratory symptoms. 1 In 1992, the Environmental Protection Agency classified SHS as a carcinogen 6 ; more than 50 carcinogens have now been identified as components of SHS. 1 , 7 – 9 The 2006 surgeon general's report found sufficient evidence to infer a causal relationship between exposure to SHS and both lung cancer and coronary heart disease. For infants and children, the evidence is sufficient to infer causality for low birthweight, sudden infant death syndrome (SIDS), lower-respiratory illness, otitis media, and asthma. 1 Each year in the United States there are an estimated 3400 lung cancer deaths, 46 000 deaths from heart disease and heart attacks, and 430 cases of SIDS resulting from SHS exposure. 10 However, the economic impact of SHS—and of efforts to limit smoking in public places—is still debated. Peer-reviewed studies have found that “smoke-free” laws have no adverse effects on hospitality industry sales and employment. 11 For example, in the 9 months following the March 2003 implementation of a “smoke-free” policy for restaurants and bars in New York City, employment in restaurants and bars increased by 10 600 jobs and taxable receipts rose by 9%. 12 The impact of SHS on health care costs is less well understood. In the United States, a study in Marion County, Indiana, identified $53.9 million in costs related to health care and premature loss of life attributable to SHS exposure—equivalent to $62.68 per capita annually. 9 A study in New York City calculated annual costs of $99 million related to infants' developmental delays caused by prenatal exposure to SHS. 13 A 2005 report from the American Society of Actuaries calculated that $2.6 billion was spent for medical care in the United States for lung cancer and heart disease (including heart attacks) in nonsmokers, caused by exposure to SHS. The report calculated an additional $3.2 billion in economic losses—including lost wages, benefits, and household services—caused by exposure to SHS. On a per-capita basis, this is equivalent to $9.02 for medical care and $11.10 for additional economic losses. 14 , 15 These studies have not used standardized methodologies or data sources, and only a few unpublished studies of the medical economic costs of SHS provide state-level findings. Because many of the policy decisions to ban smoking in public places are made at the state level, the detailed analysis presented here will be relevant to the remaining half of the states contemplating such regulations. In our study of costs related to exposure to SHS in the state of Minnesota, we used a large dataset of administrative claims data—from Blue Cross and Blue Shield of Minnesota (Blue Cross), the state's largest insurer—to estimate both the prevalence of treated medical conditions related to exposure to SHS and the costs of that treatment. These data on prevalence and costs drew on the epidemiological evidence compiled in the recent, definitive 2006 surgeon general's report of the health consequences of SHS exposure. With concepts from health services research, epidemiology, economics, and accounting, these data were extrapolated to estimate the annual health care costs of SHS to the state of Minnesota. All calculations were based on data for the year 2003, the most recent year for which all necessary epidemiological, medical, and financial data were available. The state's population that year was 5.1 million people, and the adult smoking prevalence was 18.0%. 16 In 2003, 65.3% of adult Minnesotans reported any exposure to SHS in the past 7 days. 17 Among nonsmokers—the population that was the focus of this study—the rate of exposure to SHS was 59%.
