Minnesota Department of Health
June 2011 Advisory Panel Meeting
Data Sources: (1) Youth Tobacco Survey and (2) Adult Tobacco Survey
NOTE: Both data sources are survey data
Phase I: Exploration
Prevalence
Question
Is there a high estimated proportion of
the population that is exposed to ETS?
Answer
Yes, a high proportion of the general population of
nonsmoking adults and children in the US are exposed to ETS;
43% of nonsmokers ≥4 years of age have cotinine levels that
indicate exposure to tobacco smoke (≥0.5µg/dL).
Causality
Question
Is there evidence that ETS exposure is a
component cause of adverse health
outcomes?
Answer
Yes, there are several known adverse health effects that are
linked to ETS exposure in both children and adults.
Known human carcinogen(s)
Developmental and respiratory effects in children
Respiratory, carcinogenic, and cardiovascular effects in
adults
Actionability
Question
Are there existing prevention or
control programs at MDH or other
Minnesota organizations for ETS
exposure or its adverse health
outcomes?
Can the level of ETS exposure be
modified through policy,
regulatory, or personal actions?
Answer
Yes, there are several existing programs that measure or attempt
to prevent ETS exposure or its adverse health outcomes:
Youth and Adult Tobacco Surveys
Tobacco Prevention & Control Program (MDH)
Center for Health Statistics (MDH)
Asthma Program (MDH)
Minnesota Cancer Surveillance System (MDH)
American Lung Association of Minnesota
ClearWay Minnesota and QUITPLAN
Yes, smoking bans enforced by adults or other nonsmokers and
other personal actions can reduce ETS exposure. Freedom to
Breathe (FTB), enacted in Oct 2007, prohibits smoking in virtually
all indoor public places and indoor places of employment.
However, FTB does not prohibit smoking in outdoor places or
private arena such as the car or home.
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Minnesota Department of Health
June 2011 Advisory Panel Meeting
Is ETS exposure tied to state or
federal public health objectives?
Can data and measures in this
content area be used to develop
new program initiatives?
Yes, there are five Healthy People 2020 Objectives under the
Tobacco Use (TU) topic that target ETS exposure.
1. TU-11: Reduce the proportion of nonsmokers exposed to
secondhand smoke.
2. TU-12: Increase the proportion of persons covered by
indoor worksite policies that prohibit smoking.
3. TU-13: Establish laws… on smoke-free indoor air that
prohibit smoking in public places and worksites.
4. TU-14: Increase the proportion of smoke-free homes.
5. TU-15: Increase tobacco-free environments in schools,
including all school facilities, property, vehicles, and
school events.
www.healthypeople.gov/2020/topicsobjectives2020/objectiveslis
t.aspx?topicid=41
Existing programs target either ETS exposure or its adverse health
outcomes. Tracking this content area can link the topics of
exposure with health outcome by bringing together information
on MN EPHT’s online data access portal.
Public Health Impact
Question
Can the population
attributable risk (PAR) or
public health impact of
exposure to ETS be
estimated from available
data? Or is the PAR
known?
Answer
Yes, Waters et al. (2009) estimated the economic impact and PAR of ETS
exposure in Minnesota in 2003.
Public health impact: the total cost of treatments that are causally
linked to ETS (2006 U.S. Surgeon General’s Report) was estimated at about
$229 million, adjusted to 2008 dollars.
PAR: Waters et al. (2009) also provides the PAR for several adverse
health outcomes (see table below) among Minnesota children and adults in
2003.
Table: Costs of Conditions
Attributable to Secondhand
Tobacco Smoke (SHS), by Age
Group, Minnesota, 2003.
Aged 0-17 years
Low birthweight
Acute lower-respiratory illnesses
Otitis media & middle-ear effusion
Asthma, wheeze illness
Aged 18-64 years
Lung cancer
Coronary heart disease
Aged 65+ years
Lung cancer
Coronary heart disease
Grand total
Episodes
PAR, %
Episodes
attributable
to ETS
Cost per
episode,
2003 $
Total cost,
millions,
2008 $
4,413
31,953
235,333
50,135
18.0
25.0
14.0
35.0
794
7,988
32,947
17,547
41,790
848
521
1,052
40.3
8.2
20.9
22.4
3,466
73,914
4.9
6.9
170
5100
23,200
9,650
4.8
59.7
4,450
28,033
4.9
6.9
218
1934
58,303
24,252
15.4
56.9
228.7
Source: Table 4 from Waters HR, Foldes SS, Alesci NL, Samet J. The Economic Impact of Exposure to
Secondhand Smoke in Minnesota. Am J Public Health. 2009; 99 (4): 754-759.
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Minnesota Department of Health
June 2011 Advisory Panel Meeting
(Initial) Feasibility
Question
Is there a data source for exploration of
“trackable” indicators?
Does MDH have the legal authority to collect and
use the data?
Are private data classified and protected according
to state and federal law?
Answer
Yes, there are two data sources that have data on
ETS exposure among nonsmokers in Minnesota:
Minnesota Youth Tobacco (and Asthma) Survey
and Minnesota Adult Tobacco Survey (Center for
Health Statistics, MDH).
Yes, the Center for Health Statistics has legal
authority to collect and use these data.
Yes, private data are classified and protected.
Personal identifiers do not exist in data provided
to the Tracking program. Suppression could be
applied to small cell counts for privacy.
**END OF PHASE I: EXPLORATION**
Phase II: Feasibility
Detailed Feasibility
Question
What is the level of
quality of the data?
Is there continuity?
Is the data timely?
Is the data comparable?
Is aggregation possible at
different geographic
levels?
What is the cost to MDH
to obtain data?
Answer
The data are:
population-based
representative of ETS exposure
assumed to be reliable and valid
Yes, there has been consistent data collection over time, the YTS and ATS
have been conducted since 2000 and 2003, respectively.
Yes, datasets for both surveys are typically available within a year of data
collection.
Youth Tobacco Survey (YTS):
There is the possibility to compare the youth survey to its national
counterpart and to other states that conduct that survey. For example,
CDC’s Office on Smoking & Health indicates that Minnesota and 15 other
states conducted the YTS in 2008.
Adult Tobacco Survey (ATS):
The National ATS was conducted in 2009-2010 and should have data on
ETS exposure in different settings.
CDC has a set of core questions for states conducting an ATS, but it is
unclear how many states ask standardized questions on ETS exposure.
Comparability at the state-level could be explored.
For both surveys, data are available at the state-level; in addition, it is
possible to compare regions, particularly the Twin Cities metro area vs. nonmetro regions. Aggregation is possible between years for both surveys.
There is not a prohibitive cost to MDH to obtain data and staff time to
complete these steps is reasonable.
See Piloted Data & Measures
Measure: count (#) and percent (%) of nonsmokers exposed to ETS in Minnesota.
**END OF PHASE II: FEASIBILITY**
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Minnesota Department of Health
June 2011 Advisory Panel Meeting
Phase III: Recommendation
Emerging Issues
Question
Is the degree or level of
exposure changing or
perceived to be changing?
Answer
The level of exposure in indoor public spaces (such as worksites,
restaurants, and bars) has decreased with the enactment of Freedom to
Breathe in October 2007.
The degree of exposure in homes, cars, and outdoor spaces has likely
remained the same on a population level.
It’s possible that the level of exposure on the individual level is
decreasing where parents or guardians enforcing smoking bans in the
home or car.
Potential for Information Building
Question
Is this a hazard with unknown
associations to health
outcomes or unknown level of
exposure in the population?
Are there other programs at
MDH that would be interested
in this content area?
Answer
Exposure to ETS has many known adverse health outcomes. It’s
possible that there are unknown associations yet to be discovered.
The level of exposure to ETS at the population level is measure via
cotinine (NHANES) and via surveys (such as the Youth and Adult
Tobacco Surveys).
Yes, the Center for Health Statistics, the Asthma Program, and the
Tobacco Prevention & Control Program could all potentially benefit
from display of these data and measures on MN EPHT’s web-based
data access portal and/or from topical reports on this content area.
For example, the Asthma Program is interested in resources that
would be generated on this new content area, like a data brief on ETS
exposure.
Outside Interest or Public Concern
Question
Is there a high concern
regarding the proportion of
the population exposed to
the hazard?
Is ETS exposure a priority that
has previously been
identified by environmental
health organizations?
Would this content area
utilize existing datasets in a
new way?
Answer
The proportion of the population exposed to ETS should not have
increased in recent years, especially among nonsmokers.
However, there is a high level of concern regarding vulnerable
populations being exposed to ETS, such as children and pregnant
women.
Healthy People 2020 has several objectives that target reducing the
level of exposure to ETS, especially among vulnerable populations
and increasing smoke-free venues.
NHANES measures cotinine to track the level of ETS exposure among
nonsmokers.
The Minnesota Center for Health Statistics (MDH) currently publishes
detailed reports using Youth or Adult Tobacco Survey data. However,
MN EPHT would present data and measures on ETS exposure among
nonsmokers, which is not currently addressed by existing reports. MN
EPHT would be able to present these data in a new way by focusing on
nonsmokers.
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Minnesota Department of Health
June 2011 Advisory Panel Meeting
Balance among content areas
Question
Is there balance between
hazard/exposure and disease
content areas?
Is there balance between age
groups affected among
content areas?
Answer
Yes, there is balance. MN EPHT currently tracks four hazard/exposure
content areas and four disease content areas.
Exposure to ETS would be a content area that especially affects
children, but it also affects adults and the elderly. Furthermore, there is
not currently an unbalanced representation of age groups affected by
current content areas that MN EPHT tracks.
Economic Impact
Question
What is the economic impact
in Minnesota of adding this
content area?
Answer
Adoption of ETS exposure will require the time and resources of
MN EPHT staff to incorporate the content area into Tracking.
Adoption will also require the resources of Minnesota Center
for Health Statistics staff as the data steward for both data
sources.
May also impact the work of Tobacco Prevention & Control
Program (MDH) as well as local public health programs that
have ongoing initiatives to reduce or measure ETS exposure.
Would require the collaboration with Tobacco Prevention &
Control staff to produce standardized messaging and
interpretation of data.
**END OF PHASE III: RECOMMENDATION**
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Minnesota Department of Health
June 2011 Advisory Panel Meeting
Youth Tobacco Survey (YTS)
Table 1. Percent of youth exposed to ETS* in past week among
nonsmokers, Minnesota, 2000-2008.
Year
Count
N
%
2000
5144
8551
60.2%
2002
4702
8367
56.2%
2005
4121
8199
50.3%
2008
1499
3737
40.1%
Aggregated
15466
28854
53.6%
* Exposed in the setting of “same room” OR “in a car”
Weighted %
58.8%
56.5%
50.8%
41.1%
51.5%
Percent of nonsmokers exposed to ETS
in same room or same car
Figure 1. Percent of youth exposed to ETS* in past week among
nonsmokers, Minnesota, 2000-2008.
70.0
60.0
50.0
40.0
30.0
20.0
10.0
0.0
2000
2002
2005
2008
Year
* Exposed in the setting of “same room” OR “in a car”
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Minnesota Department of Health
June 2011 Advisory Panel Meeting
Adult Tobacco Survey (ATS)
Table 1. Percent of nonsmokers exposed to ETS in the past
week by exposure setting, Minnesota adults, 2003-2010.
Year
2003
2007
2010
Aggregated
Count
497
399
157
1053
N
6996
10608
5922
23526
At home
%
7.1%
3.8%
2.7%
4.5%
Weighted %
7.4%
4.4%
3.5%
5.0%
Year
2003
2007
2010
Aggregated
Count
651
566
187
1404
N
4559
6264
3337
14160
At work
%
14.3%
9.0%
5.6%
9.9%
Weighted %
13.9%
11.1%
7.4%
10.8%
N
7000
10622
5930
23552
In a car
%
10.5%
8.1%
6.1%
8.3%
Weighted %
10.5%
9.8%
8.2%
9.5%
Year
2003
2007
2010
Aggregated
Count
734
860
359
1953
Figure 1. Percent of nonsmokers exposed to ETS in the past week by exposure
setting, Minnesota adults, 2003-2010.
At home
At work
In a car
Percent of nonsmokers exposed to ETS by
exposure setting
16.0%
14.0%
12.0%
10.0%
8.0%
6.0%
4.0%
2.0%
0.0%
2003
2007
2010
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Minnesota Department of Health
June 2011 Advisory Panel Meeting
Table 2. Percent of nonsmokers exposed to ETS in the past week in
the community,† Minnesota adults, 2003-2010.
Year
Count
N
%
Weighted %
2003
4015
6782
59.2%
60.0%
2007
4885
10571
46.2%
48.7%
2010
1889
5887
32.1%
36.5%
Aggregated
10789
23240
46.4%
48.0%
†
Exposure in the community is measured by the following survey question: “In Minnesota, in the past 7 days, has
anyone smoked near you at any place besides your home, workplace or car?”
Figure 2. Percent of nonsmokers exposed to ETS in the past week in the
community, † Minnesota adults, 2003-2010.
Percent of nonsmokers exposed to ETS
at any location
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
2003
2007
2010
†
Exposure in the community is measured by the following survey question: “In Minnesota, in the past 7 days, has
anyone smoked near you at any place besides your home, workplace or car?”
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