Open Access Research article

Exposure to second-hand smoke and direct healthcare costs in children – results from two German birth cohorts, GINIplus and LISAplus

Ariane Batscheider1, Sylwia Zakrzewska12, Joachim Heinrich3, Christina M Teuner12*, Petra Menn1, Carl Peter Bauer4, Ute Hoffmann4, Sibylle Koletzko5, Irina Lehmann6, Olf Herbarth7, Andrea von Berg8, Dietrich Berdel8, Ursula Krämer9, Beate Schaaf10, H-Erich Wichmann113, Reiner Leidl12 and the GINIplus and LISAplus study groups

Author Affiliations

1 Helmholtz Zentrum München, German Research Center for Environmental Health, Institute of Health Economics and Health Care Management, Member of the German Center for Lung Research, Neuherberg, Germany

2 Ludwig-Maximilians-Universität München, Munich School of Management - Institute of Health Economics and Health Care Management and Munich Center of Health Sciences, Munich, Germany

3 Helmholtz Zentrum München, German Research Center for Environmental Health, Institute of Epidemiology I, Member of the German Center for Lung Research, Neuherberg, Germany

4 Technical University of Munich, Department for Paediatrics, Munich, Germany

5 Ludwig-Maximilians- Universität München, Dr. von Haunersches Children’s Hospital, Munich, Germany

6 UFZ - Helmholtz Centre for Environmental Research Leipzig, Germany, Department of Environmental Immunology, Leipzig, Germany

7 University of Leipzig, Faculty of Medicine, Environmental Medicine and Hygiene, Leipzig, Germany

8 Marien-Hospital Wesel, Department of Paediatrics, Wesel, Germany

9 IUF Leibniz Research Institute for Environmental Medicine and Medical Faculty, University of Düsseldorf, Düsseldorf, Germany

10 Medical Practice for Paediatrics, Bad Honnef, Germany

11 Ludwig-Maximilians-Universität München, Institute of Medical Informatics, Biometry and Epidemiology, and Munich Center of Health Sciences, Munich, Germany

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BMC Health Services Research 2012, 12:344  doi:10.1186/1472-6963-12-344

Published: 2 October 2012



Although the negative health consequences of the exposure to second hand tobacco smoke during childhood are already known, evidence on the economic consequences is still rare. The aim of this study was to estimate excess healthcare costs of exposure to tobacco smoke in German children.


The study is based on data from two birth cohort studies of 3,518 children aged 9-11 years with information on healthcare utilisation and tobacco smoke exposure: the GINIplus study (German Infant Study On The Influence Of Nutrition Intervention Plus Environmental And Genetic Influences On Allergy Development) and the LISAplus study (Influence of Life-Style Factors On The Development Of The Immune System And Allergies In East And West Germany Plus The Influence Of Traffic Emissions And Genetics). Direct medical costs were estimated using a bottom-up approach (base year 2007). We investigated the impact of tobacco smoke exposure in different environments on the main components of direct healthcare costs using descriptive analysis and a multivariate two-step regression analysis.


Descriptive analysis showed that average annual medical costs (physician visits, physical therapy and hospital treatment) were considerably higher for children exposed to second-hand tobacco smoke at home (indoors or on patio/balcony) compared with those who were not exposed. Regression analysis confirmed these descriptive trends: the odds of positive costs and the amount of total costs are significantly elevated for children exposed to tobacco smoke at home after adjusting for confounding variables. Combining the two steps of the regression model shows smoking attributable total costs per child exposed at home of €87 [10–165] (patio/balcony) and €144 [6–305] (indoors) compared to those with no exposure. Children not exposed at home but in other places showed only a small, but not significant, difference in total costs compared to those with no exposure.


This study shows adverse economic consequences of second-hand smoke in children depending on proximity of exposure. Tobacco smoke exposure seems to affect healthcare utilisation in children who are not only exposed to smoke indoors but also if parents reported exclusively smoking on patio or balcony. Preventing children from exposure to second-hand tobacco smoke might thus be desirable not only from a health but also from an economic perspective.