December 4, 2015

Stanton A. Glantz, PhD

HUD's cost-benefit analysis of smokefree public housing (wildly) overstates costs and understates benefits

The Department of Housing and Urban Development has issued a draft rule making some public housing (cigarette and cigar) smokefree, including the required “regulatory impact analysis” (RIA, cost-benefit analysis in plain English).  Like similar analyses that the Obama Administration FDA has produced, it wildly overstates costs and understates benefits.
 
My colleagues and I at UCSF will be putting in a formal public comment on both the rule itself as well as the cost-benefit analysis, but I thought it would be worth sharing my preliminary thoughts on the regulatory impact analysis in case this information would be helpful to others.
 
The biggest issues are:
 

  • The explicitly leave out he benefits to smokers that smokefree housing makes it easier for smokers who want to quit to do so
  • They ignore the large literature (summarized in the 2014 Surgeon General report) that there are large and immediate reductions in heart attacks, strokes, and lung problems
  • They ignore evidence for similar benefits in terms of complications of pregnancy and infnat health
  • They ignore the long term impacts of secondhand smoke on childhood cognitive development and associted impacts on education costs, which are much larger than even the direct medical costs
  • They don't account for thirdhand smoke
  • The discount the limited benefits they do recognize to account for the "lost pleasure" smokers will experience if they quit

The public comments must be submitted by January 16, 2016.
 
All page numbers refer to the regulatory impact analysis.
 
Page 2, end of top para:  Are these estimates of fire damage annual amounts?  When doing the overall RIA do they account for these ongoing costs (avoids), allowing for inflation, as a savings?
 
Page 2, first full para:  How often do such evictions actually happen?
 
Page 2, last para, continuing on to page 3:  When they consider the “welfare impact on smokers,” they ignore the welfare benefits of quitting.  While not as extreme as the FDA, they assume that smokers want to keep smoking and will invest considerable time going outside to smoke cigarettes.  The reality is that something like 70% of smokers regret ever starting and a lot (I think around a third) make a quit attempt every year.  Smokefree housing both motivates and supports quit attempts (some of our relevant papers:  http://www.ncbi.nlm.nih.gov/pubmed/24114562 http://www.ncbi.nlm.nih.gov/pubmed/22099232 )  At the end of the paragraph they note that “The health benefits to smokers who are able to quit or reduce consumption may be extensive,” but later in the RIA they explicitly decline to estimate those benefits.
 
Page 5, last para:  Here they talk about how hard it is to estimate medical and other costs due to SHS and cite some very old (and shallow) papers by Gruber et al.  They completely ignore Wendy Max’s work.  I did a quick PubMed search and found this:
 

1.

Home exposure to secondhand smoke among people living in multiunit housing and single family housing: a study of California adults, 2003-2012.

 

Chambers C, Sung HY, Max W.

 

J Urban Health. 2015 Apr;92(2):279-90. doi: 10.1007/s11524-014-9919-y.

 

PMID: 25466438 [PubMed - in process]

 

Similar articles

 

2.

Secondhand smoke exposure and serum cotinine levels among current smokers in the USA.

 

Lindsay RP, Tsoh JY, Sung HY, Max W.

 

Tob Control. 2014 Nov 14. pii: tobaccocontrol-2014-051782. doi: 10.1136/tobaccocontrol-2014-051782. [Epub ahead of print]

 

PMID: 25398561 [PubMed - as supplied by publisher]

 

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3.

The healthcare costs of secondhand smoke exposure in rural China.

 

Yao T, Sung HY, Mao Z, Hu TW, Max W.

 

Tob Control. 2015 Oct;24(e3):e221-6. doi: 10.1136/tobaccocontrol-2014-051621. Epub 2014 Oct 21.

 

PMID: 25335898 [PubMed - in process] Free PMC Article

 

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4.

Childhood secondhand smoke exposure and ADHD-attributable costs to the health and education system.

 

Max W, Sung HY, Shi Y.

 

J Sch Health. 2014 Oct;84(10):683-6. doi: 10.1111/josh.12191.

 

PMID: 25154533 [PubMed - indexed for MEDLINE]

 

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5.

The cost of secondhand smoke exposure at home in California.

 

Max W, Sung HY, Shi Y.

 

Tob Control. 2015 Mar;24(2):205-10. doi: 10.1136/tobaccocontrol-2013-051253. Epub 2014 Feb 5.

 

PMID: 24500272 [PubMed - in process]

 

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6.

Attention deficit hyperactivity disorder among children exposed to secondhand smoke: a logistic regression analysis of secondary data.

 

Max W, Sung HY, Shi Y.

 

Int J Nurs Stud. 2013 Jun;50(6):797-806. doi: 10.1016/j.ijnurstu.2012.10.002. Epub 2012 Oct 26.

 

PMID: 23107006 [PubMed - indexed for MEDLINE]

 

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7.

Deaths from secondhand smoke exposure in the United States: economic implications.

 

Max W, Sung HY, Shi Y.

 

Am J Public Health. 2012 Nov;102(11):2173-80. doi: 10.2105/AJPH.2012.300805. Epub 2012 Sep 20.

 

PMID: 22994180 [PubMed - indexed for MEDLINE] Free PMC Article

 

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8.

Exposure to secondhand smoke at home and at work in California.

 

Max W, Sung HY, Shi Y.

 

Public Health Rep. 2012 Jan-Feb;127(1):81-8.

 

PMID: 22298925 [PubMed - indexed for MEDLINE] Free PMC Article

 

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Page 6, middle paragraph:  They completely ignore the rapid changes in hospitalizations for heart disease, stroke and lung disease (meta-analysis http://www.ncbi.nlm.nih.gov/pubmed/23109514 , also http://www.ncbi.nlm.nih.gov/pubmed/25997906 ), ambulance calls (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3781209/ )  and child health and complications of pregnancy (http://www.ncbi.nlm.nih.gov/pubmed/24680633 ; also see papers on right side of PubMed entry, and  http://www.ncbi.nlm.nih.gov/pubmed/26610241 http://www.ncbi.nlm.nih.gov/pubmed/26482273 , http://www.ncbi.nlm.nih.gov/pubmed/26463498 )  Also rapid drops in heart attack and LBW risk following smoking cessation:  http://www.ncbi.nlm.nih.gov/pubmed/11345384 http://www.ncbi.nlm.nih.gov/pubmed/10585982 http://www.ncbi.nlm.nih.gov/pubmed/9286934 )  Most of this material also appears in the 2014 Surgeon General’s report (starting on page 434 http://www.cdc.gov/tobacco/data_statistics/sgr/50th-anniversary/index.htm ).  It is remarkable that HUD didn’t look at the most recent Surgeon General report, which came out nearly two years ago.
 
Page 7, top line:  They rely on Kip Viscusi who has taken a lot of money from tobacco and even prepared papers on risk perception using data collected for him by industry lawyers.  See http://tobacco.ucsf.edu/sites/g/files/tkssra4661/f/u9/FDA-comment-econ-analysis-resubmit-2011-glantz-1jy-8c1p-z03c.pdf .  This comment on the FDA RIA also includes a lot of other material that will be useful in drafting this comment.
 
Page 8, bottom:  The thirdhand smoke residues hang around for a very long time and are very hard to get rid of (including from ENDS).  There is also evidence for health effects. Here some of is what a quick PubMed search for “thirdhand smoke” turned up:
 

1.

Reactions to Thirdhand Smoke are Associated with Openness to Smoking in Young Never Smoking Children.

 

Chen JJ, Ho SY, Wang MP, Lam TH.

 

J Community Health. 2015 Oct 27. [Epub ahead of print]

 

PMID: 26507651 [PubMed - as supplied by publisher]

 

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2.

Thirdhand Smoke in the Homes of Medically Fragile Children: Assessing the Impact of Indoor Smoking Levels and Smoking Bans.

 

Northrup TF, Matt GE, Hovell MF, Khan AM, Stotts AL.

 

Nicotine Tob Res. 2015 Aug 26. pii: ntv174. [Epub ahead of print]

 

PMID: 26315474 [PubMed - as supplied by publisher]

 

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3.

The Challenges of Limiting Exposure to THS in Vulnerable Populations.

 

Samet JM, Chanson D, Wipfli H.

 

Curr Environ Health Rep. 2015 Sep;2(3):215-25. doi: 10.1007/s40572-015-0060-1.

 

PMID: 26231499 [PubMed - in process]

 

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4.

Smoke-Free Multiunit Housing Policy: Caretakers' Perspectives on Economic and Personal Impacts.

 

Wilbur RE, Stein AH, Pinzon EM, Ahmed OS, McNair OS, Ribisl KM.

 

Int J Environ Res Public Health. 2015 Jul 15;12(7):8092-102. doi: 10.3390/ijerph120708092.

 

PMID: 26184274 [PubMed - in process] Free PMC Article

 

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5.

"There's no-fresh air there": narratives of smoke exposure among residents of extended-stay hotels.

 

Lewinson T, Bryant LO.

 

Health Soc Work. 2015 May;40(2):77-83.

 

PMID: 26027415 [PubMed - indexed for MEDLINE]

 

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6.

Inhalable constituents of thirdhand tobacco smoke: chemical characterization and health impact considerations.

 

Sleiman M, Logue JM, Luo W, Pankow JF, Gundel LA, Destaillats H.

 

Environ Sci Technol. 2014 Nov 18;48(22):13093-101. doi: 10.1021/es5036333. Epub 2014 Oct 31.

 

PMID: 25317906 [PubMed - in process]

 

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7.

Thirdhand cigarette smoke: factors affecting exposure and remediation.

 

Bahl V, Jacob P 3rd, Havel C, Schick SF, Talbot P.

 

PLoS One. 2014 Oct 6;9(10):e108258. doi: 10.1371/journal.pone.0108258. eCollection 2014.

 

PMID: 25286392 [PubMed - indexed for MEDLINE] Free PMC Article

 

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8.

Electronic cigarettes are a source of thirdhand exposure to nicotine.

 

Goniewicz ML, Lee L.

 

Nicotine Tob Res. 2015 Feb;17(2):256-8. doi: 10.1093/ntr/ntu152. Epub 2014 Aug 30.

 

PMID: 25173774 [PubMed - indexed for MEDLINE]

 

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9.

Thirdhand smoke beliefs of parents.

 

Drehmer JE, Ossip DJ, Nabi-Burza E, Rigotti NA, Hipple B, Woo H, Chang Y, Winickoff JP.

 

Pediatrics. 2014 Apr;133(4):e850-6. doi: 10.1542/peds.2013-3392. Epub 2014 Mar 3.

 

PMID: 24590745 [PubMed - indexed for MEDLINE] Free PMC Article

 

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10.

Children's exposure to secondhand and thirdhand smoke carcinogens and toxicants in homes of hookah smokers.

 

Kassem NO, Daffa RM, Liles S, Jackson SR, Kassem NO, Younis MA, Mehta S, Chen M, Jacob P 3rd, Carmella SG, Chatfield DA, Benowitz NL, Matt GE, Hecht SS, Hovell MF.

 

Nicotine Tob Res. 2014 Jul;16(7):961-75. doi: 10.1093/ntr/ntu016. Epub 2014 Mar 3.

 

PMID: 24590387 [PubMed - indexed for MEDLINE] Free PMC Article

 

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11.

Cigarette smoke toxins deposited on surfaces: implications for human health.

 

Martins-Green M, Adhami N, Frankos M, Valdez M, Goodwin B, Lyubovitsky J, Dhall S, Garcia M, Egiebor I, Martinez B, Green HW, Havel C, Yu L, Liles S, Matt G, Destaillats H, Sleiman M, Gundel LA, Benowitz N, Jacob P 3rd, Hovell M, Winickoff JP, Curras-Collazo M.

 

PLoS One. 2014 Jan 29;9(1):e86391. doi: 10.1371/journal.pone.0086391. eCollection 2014.

 

PMID: 24489722 [PubMed - indexed for MEDLINE] Free PMC Article

 

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12.

Thirdhand tobacco smoke: a tobacco-specific lung carcinogen on surfaces in smokers' homes.

 

Thomas JL, Hecht SS, Luo X, Ming X, Ahluwalia JS, Carmella SG.

 

Nicotine Tob Res. 2014 Jan;16(1):26-32. doi: 10.1093/ntr/ntt110. Epub 2013 Jul 26.

 

PMID: 23892827 [PubMed - indexed for MEDLINE] Free PMC Article

 

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13.

Thirdhand cigarette smoke in an experimental chamber: evidence of surface deposition of nicotine, nitrosamines and polycyclic aromatic hydrocarbons and de novo formation of NNK.

 

Schick SF, Farraro KF, Perrino C, Sleiman M, van de Vossenberg G, Trinh MP, Hammond SK, Jenkins BM, Balmes J.

 

Tob Control. 2014 Mar;23(2):152-9. doi: 10.1136/tobaccocontrol-2012-050915. Epub 2013 May 28.

 

PMID: 23716171 [PubMed - indexed for MEDLINE]

 

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14.

Thirdhand smoke and exposure in California hotels: non-smoking rooms fail to protect non-smoking hotel guests from tobacco smoke exposure.

 

Matt GE, Quintana PJ, Fortmann AL, Zakarian JM, Galaviz VE, Chatfield DA, Hoh E, Hovell MF, Winston C.

 

Tob Control. 2014 May;23(3):264-72. doi: 10.1136/tobaccocontrol-2012-050824. Epub 2013 May 13.

 

PMID: 23669058 [PubMed - indexed for MEDLINE]

 

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15.

Thirdhand smoke causes DNA damage in human cells.

 

Hang B, Sarker AH, Havel C, Saha S, Hazra TK, Schick S, Jacob P 3rd, Rehan VK, Chenna A, Sharan D, Sleiman M, Destaillats H, Gundel LA.

 

Mutagenesis. 2013 Jul;28(4):381-91. doi: 10.1093/mutage/get013. Epub 2013 Mar 5.

 

PMID: 23462851 [PubMed - indexed for MEDLINE] Free PMC Article

 

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16.

Wipe sampling for nicotine as a marker of thirdhand tobacco smoke contamination on surfaces in homes, cars, and hotels.

 

Quintana PJ, Matt GE, Chatfield D, Zakarian JM, Fortmann AL, Hoh E.

 

Nicotine Tob Res. 2013 Sep;15(9):1555-63. doi: 10.1093/ntr/ntt014. Epub 2013 Mar 4.

 

PMID: 23460657 [PubMed - indexed for MEDLINE]

 

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17.

Pediatrician interventions and thirdhand smoke beliefs of parents.

 

Drehmer JE, Ossip DJ, Rigotti NA, Nabi-Burza E, Woo H, Wasserman RC, Chang Y, Winickoff JP.

 

Am J Prev Med. 2012 Nov;43(5):533-6. doi: 10.1016/j.amepre.2012.07.020.

 

PMID: 23079177 [PubMed - indexed for MEDLINE] Free PMC Article

 

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18.

The new danger of thirdhand smoke: why passive smoking does not stop at secondhand smoke.

 

Protano C, Vitali M.

 

Environ Health Perspect. 2011 Oct;119(10):A422. doi: 10.1289/ehp.1103956. No abstract available.

 

PMID: 21968336 [PubMed - indexed for MEDLINE] Free PMC Article

 

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19.

Thirdhand tobacco smoke: emerging evidence and arguments for a multidisciplinary research agenda.

 

Matt GE, Quintana PJ, Destaillats H, Gundel LA, Sleiman M, Singer BC, Jacob P, Benowitz N, Winickoff JP, Rehan V, Talbot P, Schick S, Samet J, Wang Y, Hang B, Martins-Green M, Pankow JF, Hovell MF.

 

Environ Health Perspect. 2011 Sep;119(9):1218-26. doi: 10.1289/ehp.1103500. Epub 2011 May 31. Review.

 

PMID: 21628107 [PubMed - indexed for MEDLINE] Free PMC Article

 

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20.

Thirdhand smoke: a new dimension to the effects of cigarette smoke on the developing lung.

 

Rehan VK, Sakurai R, Torday JS.

 

Am J Physiol Lung Cell Mol Physiol. 2011 Jul;301(1):L1-8. doi: 10.1152/ajplung.00393.2010. Epub 2011 Apr 8.

 

PMID: 21478255 [PubMed - indexed for MEDLINE] Free PMC Article

 

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21.

Electronic cigarettes and thirdhand tobacco smoke: two emerging health care challenges for the primary care provider.

 

Kuschner WG, Reddy S, Mehrotra N, Paintal HS.

 

Int J Gen Med. 2011 Feb 1;4:115-20. doi: 10.2147/IJGM.S16908.

 

PMID: 21475626 [PubMed] Free PMC Article

 

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22.

Metabolites of a tobacco-specific lung carcinogen in children exposed to secondhand or thirdhand tobacco smoke in their homes.

 

Thomas JL, Guo H, Carmella SG, Balbo S, Han S, Davis A, Yoder A, Murphy SE, An LC, Ahluwalia JS, Hecht SS.

 

Cancer Epidemiol Biomarkers Prev. 2011 Jun;20(6):1213-21. doi: 10.1158/1055-9965.EPI-10-1027. Epub 2011 Apr 5.

 

PMID: 21467230 [PubMed - indexed for MEDLINE] Free PMC Article

 

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23.

Does the smoke ever really clear? Thirdhand smoke exposure raises new concerns.

 

Burton A.

 

Environ Health Perspect. 2011 Feb;119(2):A70-4. doi: 10.1289/ehp.119-a70. No abstract available.

 

PMID: 21285011 [PubMed - indexed for MEDLINE] Free PMC Article

 

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24.

Thirdhand smoke: here to stay.

 

Schick SF.

 

Tob Control. 2011 Jan;20(1):1-3. doi: 10.1136/tc.2010.040279. No abstract available. Erratum in: Tob Control. 2013 Nov;22(6):428. Schick, Suzaynn [corrected to Schick, Suzaynn F].

 

PMID: 21172855 [PubMed - indexed for MEDLINE]

 

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25.

Thirdhand smoke: heterogeneous oxidation of nicotine and secondary aerosol formation in the indoor environment.

 

Petrick LM, Svidovsky A, Dubowski Y.

 

Environ Sci Technol. 2011 Jan 1;45(1):328-33. doi: 10.1021/es102060v. Epub 2010 Dec 8.

 

PMID: 21141815 [PubMed - indexed for MEDLINE]

 

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26.

When smokers move out and non-smokers move in: residential thirdhand smoke pollution and exposure.

 

Matt GE, Quintana PJ, Zakarian JM, Fortmann AL, Chatfield DA, Hoh E, Uribe AM, Hovell MF.

 

Tob Control. 2011 Jan;20(1):e1. doi: 10.1136/tc.2010.037382. Epub 2010 Oct 30.

 

PMID: 21037269 [PubMed - indexed for MEDLINE] Free PMC Article

 

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27.

Thirdhand smoke identified as potent, enduring carcinogen.

 

Dreyfuss JH.

 

CA Cancer J Clin. 2010 Jul-Aug;60(4):203-4. doi: 10.3322/caac.20079. Epub 2010 Jun 8. No abstract available.

 

PMID: 20530799 [PubMed - indexed for MEDLINE] Free Article

 

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28.

Formation of carcinogens indoors by surface-mediated reactions of nicotine with nitrous acid, leading to potential thirdhand smoke hazards.

 

Sleiman M, Gundel LA, Pankow JF, Jacob P 3rd, Singer BC, Destaillats H.

 

Proc Natl Acad Sci U S A. 2010 Apr 13;107(15):6576-81. doi: 10.1073/pnas.0912820107. Epub 2010 Feb 8.

 

PMID: 20142504 [PubMed - indexed for MEDLINE] Free PMC Article

 

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29.

Beliefs about the health effects of "thirdhand" smoke and home smoking bans.

 

Winickoff JP, Friebely J, Tanski SE, Sherrod C, Matt GE, Hovell MF, McMillen RC.

 

Pediatrics. 2009 Jan;123(1):e74-9. doi: 10.1542/peds.2008-2184.

 

PMID: 19117850 [PubMed - indexed for MEDLINE] Free PMC Article

 

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Page 8, footnote 21:  I don’t think Sloan considers heart disease in his estimate.  While Sloan was a good estimate for its time, it is badly out of date because it does not consider any of the rapid changes in health risk that occur following end of exposure to SHS.  The public comment linked from Page 7 comment talks about this, I think.
 
Page 10, Section 2.4 – Support for smoke-free housing. The papers that they list are not specific to low-income tenants. Maya Vijayaraghavan and colleagues examined attitudes toward smoke-free policies among sheltered homeless adults and found that most were supportive of smoke-free policies. These are the people who are most likely to transition to low-income housing, thus it is important to include their perspectives under support for smoke-free housing (A Qualitative Examination of Smoke-Free Policies and Electronic Cigarettes Among Sheltered Homeless Adults.. Vijayaraghavan M, Hurst S, Pierce JP. Am J Health Promot. 2015 Nov 11  )
 
Page 11, line 3:  How big is this difference and when was it determined?
 
Page 13, first full para:  The whole focus here is on cancer, when over half the smoking deaths are heart and noncancer lung disease and 80% of secondhand smoke deaths are heart disease.
 
Page 13, Home rule:  A study using TUS-CPS 2006-2007, we found that there was a sig. disparity in home smoking rules by income level 30.4% among those below the FPL and 50.6% among those >= 300% FPL Am J Public Health. 2013 Dec;103(12):2276-83. doi: 10.2105/AJPH.2013.301300. Epub 2013 Oct 17. The effectiveness of cigarette price and smoke-free homes on low-income smokers in the United States
 
Page 13, bottom para:  Is this among people in public housing?  Given that smoking is higher in poor people, I bet that the SHS exposure levels are higher in public housing.
 
Page 14, first full para:  They do not include the benefits of making it easier for people who want to quit smoking to do so.  They also ignore the benefit of stimulating people to try and quit smoking (i.e., moving the people who say they want to stop smoking to actually trying).
 
Page 14, bottom:  Another place that they ignore rapid benefits in terms of heart disease and the other things listed above.
 
Page 17, bottom:  There are direct estimates of these effects, as noted above.  They are all in the range of 15-20% drops in events almost immediately.
 
Page 17, footnote 48:  They specifically request “data that would allow us to revise the analysis to account for the latency between SHS exposure and risk reduction in CHD and stroke.”  All the stuff listed above goes directly to this point.  (It shows the shallowness of their RIA research, since many of these papers are years old.)
 
Page 18, first sentence of first full para:  To be health protective this is a very bad idea.  It also ignores the highly nonlinear dose-response and triggering effects of smoke on cardiac events.
 
Page 22:  They ignore Wendy’s study on the long term costs of SHS exposure to kids on educational costs.
 
Page 23, table:  They leave out the costs to the education system, which are much bigger than the medical costs (per Wendy’s work).
 
Page 24, bottom:  The FDA RIA is terrible and has been the subject of extensive criticism (including a paper by Frank Chaloupka on how it underestimated the benefits of warning labels and overestimated the costs) as well as the consumer surplus discount.  They should be told NOT to use the FDA RIA as a model.
 
Page 26, middle para:  They ignore the fact that the effects of SHS on kids are lasting because of effects on long-term cognitive development.
 
Page 27, top:  The rule does not include ENDS (electronic nicotine delivery systems, or e-cigarettes).  It should be changed to include ENDS because they pollute the air and will complicate enforcement.  (Marijuana should also be explicitly included because, while it is illegal federally, more and more states are legalizing it and the use is widespread).  Including ENDS would eliminate the problem they talk about later in the paragraph.  There are also data that bystanders living with people who used ENDS have nicotine levels similar to those living with smokers.  http://www.ncbi.nlm.nih.gov/pubmed/25262078 http://www.ncbi.nlm.nih.gov/pubmed/26452675
 
Page 29, bottom:  This all assumes well-informed rational behavior, with all the problems that come with that.
 
Page 35, top para:  Our work (cited above), as well as work done by Pierce’s work at UCSD (http://www.ncbi.nlm.nih.gov/pubmed/24134354 http://www.ncbi.nlm.nih.gov/pubmed/22099231 http://www.ncbi.nlm.nih.gov/pubmed/19633273  also http://www.ncbi.nlm.nih.gov/pubmed/19346505 from Roswell Park) shows big positive effects of smokefree homes on quitting.
 
Page 35, bottom: After explicitly recognizing all these impacts on quitting as “advantageous,” “HUD does not explicitly consider these potential benefits to smokers in its analysis.  Doing so would distract from the more likely and more direct effects of the rule.”  This is ridiculous.  These are the major benefits, both short and long term.
 
Page 36, first para:  As noted in the comment on page 29, there are studies that provide direct estimates of the effect (benefit) that smokefree homes have on smoking.
 
Page 26, middle:  The 29 percent estimate of those who said they quit because of smokefree policies is consistent with our work.
 
Page 36, Voluntary household bans: The HUD RAI says that the data on voluntary smoke-free homes focus on younger, healthier individuals not representative of the public housing tenant population. Our TUS-CPS study focused on individuals living below FPL who may be more likely to live in public housing.  The actual data shows that those who had a smoke-free home were more likely to have reduced consumption and increased quitting ( 3 month abstinence) compared to those without a smoke-free home. In fact the level of quitting was similar to those living above the FPL so in effect smoke-free homes could reduce this disparity in quitting by income level. It is a cross-sectional study which comes with its limitations, but the data are focused on low-income adults.  (Am J Public Health. 2013 Dec;103(12):2276-83. doi: 10.2105/AJPH.2013.301300. Epub 2013 Oct 17. The effectiveness of cigarette price and smoke-free homes on low-income smokers in the United States)
 
Page 37, top:  This statement is way too pessimistic.  What I have seen shows that poor people care about SHS as much as rich people.
 
Page 40, 5 lines from the end of the text:  Viscusi again.
 
Page 40, bottom:  Another outrageous statement where HUD explicitly ignores the health benefits of quitting:  “Thus, although the value of longevity and quality of life is difficult to quantify, estimates are usually positive and significant.  Fully recognizing the magnitude of this potential benefit, HUD is reluctant to include a detailed analysis given that the realization of this indirect benefit depends completely on how smokers elect to comply with the rule.”  This completely ignores all the evidence noted above that it is possible to estimate the effects,
 
Page 41, end of middle paragraph:  Like  the FDA, HUD discounts the benefit of quitting because of “lost pleasure”  (although less than the FDA does):  “The net benefit to smokers who reduce their tobacco consumption would be lower than this health and longevity benefit due to loss of utility associated with the activity of smoking.  Applying Jin et al’s 33-percent utility loss estimate yields a net benefit estimate of $67 million.”  Like the FDA’s analysis, this approach ignores the fact that consumer surplus makes no sense when talking about an addictive product like cigarettes http://www.ncbi.nlm.nih.gov/pubmed/24328661 http://www.ncbi.nlm.nih.gov/pubmed/25564284 also http://www.ncbi.nlm.nih.gov/pubmed/25550419 )
 
Page 41 second to last sentence: “We request comment on the availability of evidence that distinguishes between causation and correlation in the context of indoor smoking bans’ effect on consumption and could thus be used to reasonably estimate the smoking reduction attributable to rulemaking.”  It is nice that they are asking, but disappointing that in their own research they missed so much of the available literature and are expecting the public to do HUDs work for it,
 
Page 41, last sentence: “Furthermore, we request comments on costs that would potentially be incurrent in conjunction with cessation attempts, such as increasing provision of cessation aids.”  While this is a reasonable question, it is one sided since HUD, by fiat, has excluded the benefits of quitting.  Most people quit without aids (http://www.ncbi.nlm.nih.gov/pubmed/20161722)
Page 49, middle:  The ENDS issue would be moot if ENDS were included in the rule, as they should be.
 
Page 49, footnote 153:  HUD states that “This discussion purposefully omits the health gains from reduced smoking or not smoking as they are analyzed in the section on benefits.”  This is an odd statement, since the “analysis” earlier in the RIA specifically excludes these benefits.
 
Pages 50-62:  After ignoring the substantial literature on short term benefits of ending SHS exposure and quitting smoking, HUD spends 12 pages on a detailed analysis of how long it will take smokers to walk outside and smoke a cigarette (including the average velocity of elevators), concluding that all this lost time adds up to $68 million.  This would be funny if it wasn’t forming the basis for government policy.
 
Page 68, middle paragraph:  Here HUD notes that the rule exempts dwellings in mixed-finance developments and includes only HUD’s government-owned public housing.  It also does not appear to apply to supportive housing for formerly homeless adults as these tend to be in mixed finance buildings or in private rental properties that are contracted with supportive services agencies. These are the people who have among the highest rates of tobacco use, but also the highest burden of mental illness/substance use which may make implementation/enforcement harder. The RAI does not discuss the costs of these exclusions is important.  Such a limitation is discriminatory against people living in other forms of public housing and should be dropped. 
 
Page 68, bottom:  HUD requests comments on including ENDS in its policy.  For the reasons stated above, it should include ENDS.
 
 
 

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