Cost of tobacco-related diseases, including passive smoking, in Hong Kong

Building a House on Sand: How Tobacco Use Is Devouring Resources

BACKGROUND

Tobacco is a major cause of preventable morbidity and mortality, with a considerable economic burden. The purpose of this systematic review was to summarize the evidence on the economic burden of tobacco use by searching national and international databases so as to generate useful information about the costs of tobacco use globally.

METHODS

A systematic search was conducted in Scopus, PubMed, EMBASE, ProQuest, and Web of Science (ISI) databases to identify relevant studies from 1990 to June 2021 using keywords like burden, productivity, indirect cost, direct cost, economic, monetary, expenditure, tobacco, smoking, and cigarettes. Cost estimates were converted into 2020 international dollars per adult.

FINDINGS

A total of 1,781 articles were identified, of which 361 were deemed to be eligible for inclusion. Eventually, 23 articles were found eligible. In most studies, cost estimates were provided using a prevalence-based approach. The highest total cost, as a percentage of gross domestic product (GDP), was reported for South Korea (1.19%). Noteworthy, in all studies, indirect costs accounted for the highest proportion of all costs. The mean total cost amounted to 5,866 million dollars. The direct costs ranged from 179 million dollars in South Korea to 8,156 million dollars in Israel. Meanwhile, the indirect costs ranged from 289 million dollars in Hong Kong to 9,808 million dollars in India.

CONCLUSION

The evidence demonstrated the considerable economic burden of tobacco use in various countries, ranging from 0.33 to 1.19% of the GDP of the investigated countries, indicating the necessity of taking immediate measures. Hence, policies are needed to address the economic burden of smoking.

Concordance assessment through comparison with urine cotinine: Does self-report adequately reflect passive smoking?

INTRODUCTION

There is a paucity of studies evaluating passive smoking (PS) by comparing self-report (SR) and biomarkers. Our study aimed to confirm whether SR could accurately reflect PS compared to biomarkers, a golden standard for assessing the exposure of non-smokers.

METHODS

We used the 2014-2020 Korea National Health and Nutrition Examination Survey data and selected 29622 non-smokers aged >19 years as the study participants. The PS rate by SR was assessed during the last 7 days, and participants were interviewed to investigate their exposure at home, work, indoors, and in public places. In addition, participants having a limit of detection ≥0.5 ng/mL in urine cotinine (UC) was defined as the exposure group. All analyses reflected the weights of complex sampling. We first compared the rates of PS using biomarkers and SR, and then the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated based on biomarkers.

RESULTS

PS exposure by UC was the highest (44.4%), and the exposure by SR was significantly lower (5.1-29.5%). Kappa and sensitivity in PS in the indoor home (HPS) were lower than those in indoor workplaces (WPS) and indoor public places (PPS). Moreover, overall sensitivity and PPV were lower, and specificity and NPV were relatively higher in accuracy. Lastly, the sensitivity was poor, and the specificity was relatively good, which means that measurement by SR would identify people who were actually exposed to PS as non-exposed.

CONCLUSIONS

Despite exposure to PS, the use of the SR method is more likely to classify participants in the non-exposed group. Hence, to overcome measurement error in SR and reflect exposure in any place and setting, biomonitoring and SR should be performed.

The estimated effect of graphic warning labels on smoker's intention to quit in Shanghai, China: a cross-sectional study

BACKGROUND

Tobacco consumption is the leading cause of death worldwide. Overwhelming studies demonstrate graphic warning labels (GWLs) on cigarette packs are effective in eliciting negative response to tobacco smoking, modifying beliefs about tobacco dangers, and increasing reported intention to quit, but the estimated effect of GWLs on smoking cessation intention among smokers is still limited in China. In this study, we aim to understand the smoking intensity, smoking duration and smoking cessation intention among current smokers, and to explore how their smoking cessation intention would be influenced by the GWLs in Shanghai.

METHODS

From January to June 2021, we totally recruited 1104 current smokers in Songjiang district and Fengxian district of Shanghai by multistage sampling design. We used Android pad assisted electronic questionnaire for data collection, and then implemented logistic regression for odds ratio (OR) and 95% confidence interval (CI) calculation to explore how smoking cessation intention would be influenced by the GWLs among current smokers.

RESULTS

One thousand one hundred four current smokers included 914 males (82.79%), with an average age of 43.61 years. 58.06% of current smokers reported smoking cessation intention due to GWLs. Logistic regression indicated a higher percentage of smoking cessation intention due to GWLs was among female smokers [OR = 2.41, 95% CI (1.61-3.59)], smokers with smoking intensity < 20 cigarette/day [OR = 1.92, 95% CI (1.44-2.55)], smokers with tobacco burden < 20% [OR = 1.94, 95% CI (1.35-2.79)], and among smokers had plan to quit in a year [OR = 6.58, 95% CI (4.71-9.18). Smokers with higher individual monthly income had lower percentage of smoking cessation intention (OR were 0.35, 0.46 and 0.41). Meanwhile, among 642 current smokers without plan to quit in a year, approximately 40% of them reported smoking cessation intention due to GWLs.

CONCLUSIONS

Smoking cessation intention due to the assumed GWLs on cigarette packs is high among current smokers in Shanghai, especially in female smokers, smokers with light tobacco burden and mild nicotine dependence. Incorporating smoking intensity as well as smoking burden into the implementation of GWLs as tobacco control measures would discourage smoking in China.

The Estimated Effect of Physicians' Advice for Smoking Cessation and Assumed Tobacco Retail Price Increase on Smoker's Intention to Quit in Shanghai, China: A Cross-Sectional Study

Background: Tobacco consumption produces a heavy disease burden worldwide, and tobacco price increase, an advertisement for tobacco-induced harm, graphic warning labels on cigarette packages and advice of physicians for quitting are policies that have been proved as effective smoking cessation measures. But evidence on the estimated effect of advice of physicians for quitting and assumed tobacco retail price increase on smoking cessation intention among smokers is still limited in China. Methods: From January to April of 2021, we recruited 664 current smokers in Songjiang district of Shanghai by a multistage sampling design. We implemented a logistic regression analysis to calculate the odds ratio (OR) and 95% confidence interval (CI) to explore how smoking cessation intention would be influenced by the assumed tobacco retail price increase as well as advice of physicians for quitting, and used the paired tabulation method to identify the salient tobacco control measures among smokers as well. Results: A total of 664 current smokers included 548 males (82.53%), with an average smoking duration of 22.50 years (SD: 11.52 years). About 68.79 and 43.67% of current smokers reported smoking cessation intention due to advice of physicians for quitting and the assumed tobacco retail price increase, respectively. Logistic regression analysis indicated that female smokers (OR = 2.85 and 4.55), smokers with previous smoking cessation attempt (OR = 3.71 and 3.07), longer smoking duration (OR = 2.26 and 2.68), lower smoking intensity (OR = 1.82 and 1.69), and heavier tobacco burdens (OR = 1.67 and 2.22) had the higher intention of smoking cessation both due to advice of physicians for quitting and due to assumed tobacco price increase, respectively. Meanwhile, the advice of physicians for quitting was more effective and acceptable (over 80%) than the assumed tobacco price increase for inducing smokers to consider quitting in Shanghai. Conclusions: Smokers have a high intention of smoking cessation in Shanghai, and the advice of physicians for quitting is a potentially more salient tobacco control measure than the assumed tobacco retail price increase. Incorporating smoking duration, intensity, personal burden as well as noncommunicable disease (NCD) status of smokers into the implementation of tobacco control measures is beneficial for descending smoking prevalence.

Help me quit smoking but don't make me sick! The controversial effects of electronic cigarettes on tobacco smokers

Despite its increasing use, little is known about the effect of electronic cigarette. This study estimates the impact of the use of electronic cigarettes on tobacco smoking and health among tobacco smokers, using French panel data derived from the Health, Health Care, and Insurance Survey for 2010-2014. We use a difference-in-differences propensity score matching approach to identify the effect of electronic cigarette use on a sample of 982 smokers. We show that the use of electronic cigarettes increases the probability of quitting smoking and reduces the number of regular cigarettes smoked per day. However, we also find evidence that electronic cigarette users have a higher probability of reporting poor health status and suffering from a chronic disease compared with those who only smoke regular cigarettes. Overall, our results do not support the use of electronic cigarettes for tobacco smokers.

Economic cost of tobacco smoking and secondhand smoke exposure at home in Thailand

IntroductionSmoking is an important public health concern. This study is the first that attempts to estimate the economic cost of smoking and secondhand smoke (SHS) exposure at home in Thailand.MethodA prevalence-based cost of illness approach following the guideline by WHO is employed.ResultIn 2017, the direct morbidity cost attributable to smoking and SHS exposure at home in Thailand was estimated to be at least US$265.97 million and US$23.66 million, respectively. Indirect morbidity costs from workday loss totalling US$25.04 million can be linked to smoking, while US$1.72 million was the result of SHS exposure at home. Smoking-attributable premature deaths resulted in an opportunity loss to the country equivalent to US$2.48 billion, while the figure was US$181.41 million for SHS exposure at home. Total years of life lost due to smoking and SHS-attributable premature deaths are estimated to have been at least 390 955 years for males and 82 536 years for females. The total economic cost from both types of tobacco exposure amounted to US$2.98 billion, equivalent to 17.41% of Thailand's current health expenditure or 0.65% of its gross domestic product in 2017.ConclusionSmoking imposed a substantial economic burden on Thailand in 2017. Seven per cent of this cost was imposed on non-smokers sharing a residence with smokers. Females bore 80% of this SHS-related cost. The findings call for prompt responses from public health agencies in Thailand to launch effective tobacco control policies.

Nomogram to predict successful smoking cessation in a Chinese outpatient population

INTRODUCTION

The study aimed to establish and internally validate a nomogram to predict successful smoking cessation in a Chinese outpatient population.

METHODS

A total of 278 participants were included, and data were collected from March 2016 to December 2018. Predictors for successful smoking cessation were evaluated by 3-month sustained abstinence rates. Least absolute shrinkage and selection operator (LASSO) regression was used to select variables for the model to predict successful smoking cessation, and multivariable logistic regression analysis was performed to establish a novel predictive model. The discriminatory ability, calibration, and clinical usefulness of the nomogram were determined by the concordance index (C-index), calibration plot, and decision curve analysis, respectively. Internal validation with bootstrapping was performed.

RESULTS

The nomogram included living with a smoker or experiencing workplace smoking, number of outpatient department visits, reason for quitting tobacco, and varenicline use. The nomogram demonstrated valuable predictive performance, with a C-index of 0.816 and good calibration. A high C-index of 0.804 was reached with interval validation. Decision curve analysis revealed that the nomogram for predicting successful smoking cessation was clinically significant when intervention was conducted at a successful cessation of smoking possibility threshold of 19%.

CONCLUSIONS

This novel nomogram for successful smoking cessation can be conveniently used to predict successful cessation of smoking in outpatients.

Exploring smoking cessation behaviors of outpatients in outpatient clinics: Application of the transtheoretical model

To examine the knowledge, attitudes, and behaviors of smokers towards smoking prevention and provide high-quality smoking cessation services and education on tobacco prevention and establish a smoke-free care network.This study is a cross-sectional survey. The research tool is a questionnaire composed of 4 sub-scales, namely, "tobacco harm awareness," "tobacco prevention attitude," "quitting smoking self-efficacy scale," and "intentional behavior to quit smoking."A positive correlation was identified between cessation-specific knowledge, attitude to quit smoking, and intentional behavior to quit smoking among outpatients. Following the regression analysis, 2 factors (cessation-specific knowledge and attitude toward quitting the smoking habit) were considered in the model and its total variance explained reached 53.2%.Regular smoking cessation classes should be conducted to increase the awareness of smoking hazards and improve the positive attitude toward smoking cessation to avoid smoking hazards.

Economic burden of smoking-attributable diseases in China: A systematic review

INTRODUCTION

This review aims to synthesise the studies on smoking-attributable burden of diseases in China to assess the economic burden of smoking and highlight the weakness in these studies to inform future studies.

METHODS

A systematic search of studies on smoking-attributable burden of disease in seven databases was conducted in 2019 and studies were screened according to inclusion and exclusion criteria. The evaluation of studies was based on the seven key elements for burden of disease studies. Costs were converted into 2013 Renminbi (RMB), with 1000 RMB about 163 US$ in 2013, the year of the first search, using the Consumer Price Index and the then exchange rate.

RESULTS

Twenty studies were identified that estimated the costs of smoking in China, ranging from 57.162 to 368.273 billion RMB in total. The largest proportion of direct costs was allocated to outpatient visits, accounting for 49.17-68.94% of the direct costs. Meanwhile, costs resulting from mortality constituted 64.52-98.82% of the indirect costs. In mainland China, the understanding of PAR% (ratio of population attributable risk and incidence in the total population) in studies is not consistent. Studies on the cost of passive smoking are lacking and the research method for diseases needs to be improved.

CONCLUSIONS

Smoking-attributable diseases have exerted substantial direct and indirect economic burden on China. The methodologies for future studies should be improved. Hong Kong and Taiwan provide good examples for future research in mainland China and researchers there should use PAR% correctly. More studies on the burden of passive smoking should be conducted. We propose a combination of single and all-disease research methods, if data are sufficient.

Relationships between smoking duration, smoking intensity, hypothetical tobacco price increases, and smoking habit change intention among current smokers in Shanghai

Objectives

We conducted a cross-sectional study to explore the effect of a hypothetical tobacco retail price increase on smoking habit change intention, and the role of smoking duration and intensity in smoking change intention.

Methods

In 2016 and 2017, we collected questionnaire data from 36,698 residents aged over 18 years in Songjiang district, Shanghai. Chi-square tests and weighted logistic regression were used for data analyses.

Results

The prevalence of current smoking was 19.78% (men: 48.36% and women: 0.22%). A total of 10.83% (men: 10.89% and women: 2.04%) and 9.39% of smokers (men: 9.42% and women: 6.12%) expressed the intention to smoke less or quit, respectively, given tobacco retail price increases. If the current tobacco retail price doubled, 75% of smokers stated that they would smoke less and 60% of smokers would consider quitting. Smokers with longer smoking duration and lower smoking intensity were more sensitive to tobacco price increases and more likely to change their smoking habits.

Conclusions

An increase in tobacco retail prices could induce some smokers to change their smoking behavior, particularly those with longer smoking duration and lower smoking intensity. A tobacco retail price increase is recommended, which should apply to all cigarette brands.

Burden of smoking in Brazil and potential benefit of increasing taxes on cigarettes for the economy and for reducing morbidity and mortality

The prevalence of smoking in Brazil has decreased considerably in recent decades, but the country still has a high burden of disease associated with this risk factor. The study aimed to estimate the burden of mortality, morbidity, and costs for society associated with smoking in 2015 and the potential impact on health outcomes and the economy based on price increases for cigarettes through taxes. Two models were developed: the first is a mathematical model based on a probabilistic microsimulation of thousands of individuals using hypothetical cohorts that considered the natural history, costs, and quality of life of these individuals. The second is a tax model applied to estimate the economic benefit and health outcomes in different price increase scenarios in 10 years. Smoking was responsible for 156,337 deaths, 4.2 million years of potential life lost, 229,071 acute myocardial infarctions, 59,509 strokes, and 77,500 cancer diagnoses. The total cost was BRL 56.9 billion (USD 14.7 billion), with 70% corresponding to the direct cost associated with healthcare and the rest to indirect cost due to lost productivity from premature death and disability. A 50% increase in cigarette prices would avoid 136,482 deaths, 507,451 cases of cardiovascular diseases, 64,382 cases of cancer, and 100,365 cases of stroke. The estimated economic benefit would be BRL 97.9 billion (USD 25.5 billion). In conclusion, the burden of disease and economic losses associated with smoking is high in Brazil, and tax increases are capable of averting deaths, illness, and costs to society.

Prevalence of tobacco related chronic diseases and its role in smoking cessation among smokers in a rural area of Shanghai, China: a cross sectional study

BACKGROUND

Tobacco smoking is a recognized risk factor for many chronic diseases and previous study evidences have indicated that smokers receive smoking cessation service after the diagnosis of chronic diseases increases successful rate in quitting. But the prevalence of tobacco related chronic diseases (TCD) among smokers, as well as the role of TCD diagnosis in smoking cessation is still unclear in China.

METHODS

From June 2016 to December 2017, we sampled 36, 698 residents aged over 18 years by a three stage sampling in Songjiang district, Shanghai. We conducted a cross-sectional study to understand the prevalence of TCD among smokers, and the role of TCD diagnosis in smoking cessation among ex-smokers as well as the smoking cessation attempt among current smokers.

RESULTS

Over all, the prevalence of current smoking is 19.78% (48.36% for male and 0.22% for female). 15.93% of smokers have stopped smoking successfully (1, 376/8, 636). The prevalence of ten selected TCDs among smokers range from 0.63% (Chronic Obstructive Pulmonary Disease, COPD) to 36.31% (hypertension). All of 1, 376 ex-smokers had at least one kind of TCD, and 52.33% of them stop smoking after the diagnosis of TCD, the time interval between TCD diagnosis and smoking cessation ranges from 0 to 65 years, with a median of 9 years. Smokers with TCD had higher prevalence of quit smoking, and current smokers with TCD had higher smoking cessation attempt proportion.

CONCLUSIONS

The prevalence of current smoking is still very high among male residents in rural area of Shanghai, and the occurrence of TCD even non-lethal one could provide an opportunity for doctors to assist the smoking cessation among smokers.

Adolescent Smoking in Hong Kong: Prevalence, Psychosocial Correlates, and Prevention

Preventing adolescent smoking is important as smoking is typically initiated by young people. This article reviews the prevalence, psychosocial correlates, and prevention of smoking in Hong Kong adolescents. The past 30-day smoking prevalence in adolescents decreased from 9.6% in 2003 to 2.5% in 2017. Tobacco advertisements, parental and best friends smoking, nonintact families, poor family relationships, lower socioeconomic status, being a new immigrant, poor knowledge of smoking-related harm, positive attitudes toward smoking, overestimation of peer smoking, and depressive symptoms were positively associated with smoking outcomes, whereas positive youth development, authoritative mother and permissive father, family functioning, school competence, and stronger tobacco industry denormalization beliefs were protective against smoking. Along with tobacco tax increase, ban on tobacco advertisements, smoke-free law and pictorial warnings, educational efforts through theater performances, social norms campaigns, and positive adolescent training programs have been conducted to prevent adolescent smoking. To achieve the ultimate goal of tobacco endgame, further tax increase, plain packaging, banning point-of-sale display of tobacco products, smoke-free area extension, and raising minimum age of purchase should be implemented. The government proposed law to ban e-cigarettes, and heated tobacco products should be passed soon to protect children and adolescents from using these products.

Economic Costs Attributable to Smoking in Hong Kong in 2011: A Possible Increase From 1998

BACKGROUND

Reduction in smoking prevalence does not necessarily reduce the costs of smoking as evidence shows in developed countries. We provide up-to-date estimates for direct and indirect costs attributable to smoking in Hong Kong in 2011 and compare with our 1998 estimates.

METHODS

We took a societal perspective to include lives and life years lost, health care costs and time lost from work in the costing. We followed guidelines on estimating costs of active smoking for those aged 35 years or above (35+) and costs due to second-hand smoking (SHS) exposure for 35+, infants aged 12 months and under and children aged 15 and below. All costs are in US dollars.

RESULTS

We estimated that 6154 deaths among 35+ in Hong Kong in 2011 were attributable to active smoking, an increase of 10% from 1998. Besides, 672 deaths were attributable to SHS exposure, that is, 10% of the total 6826 smoking-attributable deaths. The estimate of productive life lost due to deaths from active smoking by those aged under 65 years in 2011 was $166 million, an increase of about 4% over the estimate in 1998. Our conservative estimate of the annual tobacco-related disease cost in 2011 was $716 million which accounted for 0.3% of GDP. If we added the value of attributable lives lost, the annual cost would be $4.7 billion.

CONCLUSION

Despite the reduction in smoking prevalence, smoking-attributable disease still imposes a substantial economic burden on Hong Kong society. These findings support more stringent and effective tobacco control legislation, policies, and measures.

IMPLICATIONS

Current evidence shows reduction in smoking prevalence does not necessarily reduce the economic costs of smoking. Most studies in developed countries employed a societal perspective, including costs of productivity loss and indirect costs, but not all studies estimated costs associated with second-hand smoking (SHS). The present study estimated the total costs of smoking in Hong Kong including direct and indirect costs attributable to active smoking and to SHS exposure. Our study confirms the pattern of smoking epidemic in developed countries, forewarns the increasing economic burdens from tobacco, and provides East Asian countries with a prediction of their own future costs.

Smoking behaviours of Hong Kong Chinese hospitalised patients and predictors of smoking abstinence after discharge: a cross-sectional study

OBJECTIVES

Patients admitted to hospitals represent an excellent teachable moment for smoking cessation, as they are required to abstain from tobacco use during hospitalisation. Nevertheless, smoking behaviours of hospitalised patients, and factors that lead to smoking abstinence thereafter, remain relatively underexplored, particularly in a Hong Kong Chinese context. This study aimed to examine the smoking behaviours of hospitalised patients and explore factors leading to their abstaining from cigarette use after being hospitalised.

DESIGN

A cross-sectional design was employed.

SETTING

This study was conducted in three outpatient clinics in different regions in Hong Kong.

PARTICIPANTS

A total of 382 recruited Chinese patients.

PRIMARY AND SECONDARY OUTCOME MEASURES

The patients were asked to complete a structured questionnaire that assessed their smoking behaviours before, during and after hospitalisation.

RESULTS

The results indicated 23.6% of smokers smoked secretly during their hospital stay, and about 76.1% of smokers resumed smoking after discharge. Multivariate logistic regression analysis found that number of days of hospitalisation admission in the preceding year (OR 1.02; 95% CI 1.01 to 1.27; p=0.036), patients' perceived correlation between smoking and their illness (OR 1.08; 95% CI 1.01 to 1.17; p=0.032), withdrawal symptoms experienced during hospitalisation (OR 0.75; 95% CI 0.58 to 0.97; p=0.027) and smoking cessation support from healthcare professionals (OR 1.18; 95% CI 1.07 to 1.36; p=0.014) were significant predictors of smoking abstinence after discharge.

CONCLUSIONS

The results of this study will aid development of appropriate and innovative smoking cessation interventions that can help patients achieve more successful smoking abstinence and less relapse.

TRIAL REGISTRATION NUMBER

NCT02866760.

Comparison of two approaches in achieving smoking abstinence among patients in an outpatient clinic: A Phase 2 randomized controlled trial

OBJECTIVES

To compare the effectiveness of quitting immediately and cutting down to quit in promoting smoking abstinence among smokers in an outpatient clinic.

METHODS

A total of 100 subjects were randomized into two groups, 50 in the quit immediately group, who received an intervention on abruptly quitting, and 50 in the cut down to quit group, who received an intervention on gradual reduction. All subjects were followed up at 6 and 12 months via telephone. The intention-to-treat principle was used.

RESULTS

At the 6-month follow-up, the self-reported quit rate of subjects in the quit immediately group was significantly higher than in the cut down to quit group (18.0% vs. 4.0%, p = 0.04). However, this difference was not significant at the 12-month follow-up (12.0% vs. 4.0%, p = 0.16).

CONCLUSION

These data suggest that quitting immediately might be more effective than cutting down to quit at 6 months but not at 12 months.

PRACTICE IMPLICATIONS

It is crucial to allow smokers to select quitting immediately or reducing the number of cigarettes smoked. Further studies are warranted to compare the effectiveness of various approaches for achieving smoking abstinence.

Smoking-Attributable Direct Healthcare Expenditure in Lithuania: A Prevalence-Based Annual Cost Approach

Introduction: The estimates of the economic burden of smoking provide the basis for a comprehensive assessment of the overall economic impact and evidence for potential public health policy intervention by the government. The aim of this paper is to estimate the smoking-attributable direct healthcare expenditure covered by the Compulsory Health Insurance Fund (CHIF) in Lithuania in 2013. Methods: A prevalence-based and disease-specific annual cost approach was applied to 25 smoking-related diseases or disease categories. Our analysis included only direct government healthcare expenditure (reimbursed by CHIF), including: smoking-attributable outpatient and inpatient care services, medical rehabilitation, reimbursable and publicly procured pharmaceuticals and medical aids, the emergency medical aid (ambulance) service, nursing, and expensive tests and procedures. The smoking-attributable expenditure on the above-mentioned healthcare services was calculated by multiplying the total annual expenditure by the corresponding smoking attributable fractions (SAFs). Results: The total smoking-attributable government expenditure amounted to €37.4 million in 2013. This represented 3% of the total CHIF budget in 2013. Smoking-attributable expenditure on inpatient care and medical rehabilitation services was two times higher for male smokers, than for female smokers. Conclusions: Smoking imposes a significant preventable financial cost within the budget of the Lithuanian healthcare system. A quantitative estimation of smoking related healthcare costs could provide an incentive for the development of smoking cessation services, with additional attention towards male smokers, as well as an important focus on smoking prevention among children and youths.

Proactive outreach smoking cessation program for Chinese employees in China

We evaluated the first workplace intervention to help smokers quit in Hong Kong. Smoking employees (N = 642) received a 26-page self-help booklet and 15 fix SMS within 3 months and chose to receive cognitive behavioral workshop (N = 76), or face-to-face counseling (N = 11), or group health talk (N = 516), or telephone counseling (N = 39). Twenty participants were interviewed individually for their opinions about the interventions. By intention-to-treat, the overall self-reported past 7-day point prevalence quit rate was 31.0% and 32.9%, and reduction rate was 15.0% and 13.2% at 6 and 12-months, respectively. More than 20% of the unmotivated smokers at baseline (N = 399) quit in this program. Proactive outreach workplace smoking cessation programs with diverse intensity but without medications, chosen by smokers and supported by employers without further incentives, were feasible in busy working environment in Hong Kong.

Health Care Cost of Noncommunicable Diseases Related to Smoking in Indonesia, 2015

This study aimed to estimate the current prevalence and treatment cost of noncommunicable diseases attributed to tobacco in the Indonesian population in 2015. An epidemiological study was performed. Using the national universal coverage database, we calculated the morbidity and treatment cost of 19 diseases. Proportion of smoking-attributed diseases and treatment costs because of smoking were calculated using smoking-attributable fraction. The study revealed that the morbidity of smoking-related diseases accounted for 991 331 cases, about 21.6% of total cases of chronic diseases in Indonesia. The highest incidences of disease were hypertension, chronic obstructive pulmonary diseases, and ischemic heart disease. The treatment cost of smoking in Indonesia was conservatively estimated to be at least US$2177 million, approximately 2.5% of the 2015 gross domestic product. A majority of the cost was largely concentrated in the male population (US$2164 million). Treatment costs of hypertension, chronic obstructive pulmonary diseases, and ischemic heart disease had the highest cost burden. This study's findings provide scientific evidence about the economic burden of smoking, particularly the health care expenditure covered by the government. This study's evidence is important for informing national public health policy to advocate the health promotion and prevention program.

Economic Burden of Smoking in Iran: A Prevalence-Based Annual Cost Approach

Objectives:

The burden of smoking on the health system and society is significant. The current study aimed to estimate the annual direct and indirect costs of smoking in Iran for the year 2014.

Methods:

A prevalence-based disease-specific approach was used to determine costs associated with the three most common smoking-related diseases: lung cancer (LC), chronic obstructive pulmonary disease (COPD) and ischaemic heart disease (IHD). Data on healthcare utilization were obtained from an original survey, hospital records and questionnaires. The number of deaths was extracted from the global burden diseases study (GBD). The human capital approach was applied to estimate the costs of morbidity and mortality due to smoking-related diseases, classified as direct (hospitalization, outpatients and non-medical costs) and indirect (mortality and morbidity).

Results:

The total economic cost of the three most common smoking-attributable diseases in Iran was US$1.46 billion in 2014, including US$1.05 billion (71.7%) in indirect and US$0.41 billion (28.3%) in direct costs. Direct costs of the three smoking-related diseases accounted for 1.6% of total healthcare expenditures and total costs were about 0.26% of Iran’s gross domestic product (GDP) in 2014.

Conclusions:

Our study indicated that smoking places a substantial economic burden on Iranian society. Therefore, sustained smoking cessation interventions and tobacco control policies are required to reduce the magnitude and extent of smoking-attributable costs in Iran.

A Brief Smoking Cessation Advice by Youth Counselors for the Smokers in the Hong Kong Quit to Win Contest 2010: a Cluster Randomized Controlled Trial

Smoking cessation counseling by healthcare professionals is effective, but very few healthcare professionals can deliver these interventions in the busy clinical settings. This study aimed to evaluate the effectiveness of a brief smoking cessation advice delivered by briefly-trained youth counselors at the enrolment of an incentive-based smoking cessation campaign. The study design was a cluster 2-arm randomized controlled trial of 831 Chinese adult smokers who were recruited in public areas to participate in the Hong Kong Quit to Win Contest 2010. The intervention group (n = 441) received a 5-min quitting advice from the youth counselors, who were mainly undergraduate nursing students, and a 12-page self-help smoking cessation booklet at the enrolment, while the control group (n = 390) only received the same booklet. Biochemically confirmed quitters at 6-month follow-up could join a lucky draw that offered HK$10,000 (US$1282) cash prize to three winners and HK$4000 gift vouchers to the other 10 winners. Primary outcome was self-reported smoking abstinence at 6-month follow-up. By intention-to-treat, the intervention group had a non-significantly higher self-reported (18.4 versus 13.8%, OR = 1.40, 95% CI 0.96-2.04, p = 0.08) and validated quit rate (9.1 versus 6.7%, OR = 1.40, 95% CI 0.84-2.33, p = 0.20) than the control group at 6-month follow-up. The analysis with multiple imputation for missing data also found similar results. We concluded that the brief on-site advice by trained youth counselors had a modest effect on smoking cessation, but the effect was not significant. Future studies with larger sample size and results from higher participation of the biochemical validation to confirm the effectiveness are warranted.

Modeling lifetime costs and health outcomes attributable to secondhand smoke exposure at home among Korean adult women

PURPOSE

The aim of this research is to estimate lifetime costs and health consequences for Korean adult women who were exposed to secondhand smoke (SHS) at home.

METHODS

A Markov model was developed to project the lifetime healthcare costs and health outcomes of a hypothetical cohort of Korean women who are 40 years old and were married to current smokers. The Korean epidemiological data were used to reflect the natural history of SHS-exposed and non-exposed women. The direct healthcare costs (in 2014 US dollars) and quality-adjusted life years (QALYs) were annually discounted at 5% to reflect time preference. The time horizon of the analysis was lifetime and the cycle length was 1 year. Deterministic and probabilistic sensitivity analyses were conducted.

RESULTS

In the absence of SHS exposure, Korean women will live 41.32 years or 34.56 QALYs before discount, which corresponded to 17.29 years or 15.35 QALYs after discount. The SHS-exposed women were predicted to live 37.91 years and 31.08 QALYs before discount and 16.76 years and 14.62 QALYs after discount. The estimated lifetime healthcare cost per woman in the SHS non-exposed group was US$11 214 before the discount and US$2465 after discount. The negative impact of SHS exposure on health outcomes and healthcare costs escalated as the time horizon increased, suggesting that the adverse impact of SHS exposure may have higher impact on the later part of the lifetime. The result was consistent across a wide range of assumptions.

CONCLUSION

Life expectancy might underestimate the impact of SHS exposure on health outcomes, especially if the time horizon of the analysis is not long enough. Early intervention on smoking behaviour could substantially reduce direct healthcare costs and improve quality of life attributable to SHS exposure.

Smoking and Secondhand Smoke Exposure at Home Were Associated with Poor Perceived Family Well-Being: Findings of FAMILY Project

INTRODUCTION

To investigate the associations of cigarette smoking and secondhand (SHS) exposure at home with family well-being among Chinese adults in Hong Kong.

METHODS

Telephone surveys were conducted among 3043 randomly selected adults (response rate 70%) in 2010 and 2012 to monitor family health information and tobacco use in Hong Kong. Family well-being was measured using three questions of perceived family harmony, happiness and health (3Hs) with responses ranging from 0-10 and a higher score indicating better family well-being. Smoking status, nicotine dependence, quitting behaviours and SHS exposure at home were recorded. Multiple linear regressions were used to calculate β-coefficients for individual family 3Hs component and an overall composite score representing family well-being.

RESULTS

Compared with never smokers, current smokers reported lower levels of family harmony (adjusted β = -0.15, 95% CI: -0.35 to -0.10), happiness (adjusted β = -0.12, 95% CI: -0.28 to -0.02), health (adjusted β = -0.15, 95% CI: -0.30 to -0.03) and overall family well-being (adjusted β = -0.17, 95% CI: -0.32 to -0.06). Quit attempt and intention to quit were not associated with family well-being. SHS exposure at home was associated with lower levels of family harmony (adjusted β = -0.17, 95% CI: -0.30 to -0.07), happiness (adjusted β = -0.19, 95% CI: -0.32 to -0.08), health (adjusted β = -0.13, 95% CI: -0.26 to -0.03) and family well-being (adjusted β = -0.19, 95% CI: -0.32 to -0.09).

CONCLUSIONS

Smoking and SHS exposure at home were associated with the lower levels of perceived family well-being. Prospective studies are needed to confirm the results.

Motivating smokers at outdoor public smoking hotspots to have a quit attempt with a nicotine replacement therapy sample: study protocol for a randomized controlled trial

BACKGROUND

About half of the daily smokers in Hong Kong have never tried and have no intention to quit smoking. More than one-third (37.9 %) of daily smokers have attempted to quit but failed. Nicotine replacement therapy (NRT) is a safe and effective pharmacotherapy to increase abstinence by reducing withdrawal symptoms during the early stage of smoking abstinence. However, the prevalence of NRT use in Hong Kong is lower than in most developed countries. The proposed study aims to assess the effectiveness of providing free NRT samples to smokers on increasing quit attempts and the quit rate.

METHODS

Trained university undergraduate students as ambassadors will invite smokers at outdoor public smoking hotspots to participate in the randomized controlled trial, in which eligible smokers will be randomized to receive a 1-week free NRT sample and medication counselling (intervention) or advice to purchase NRT on their own (control). The primary outcome is self-reported quit attempts (no smoking for at least 24 hours) in the past 30 days at 1-month and 3-month telephone follow-up.

DISCUSSION

The findings will inform the effectiveness of delivering free NRT samples at outdoor public smoking hotspots to increase quit attempts and abstinence. The study will also provide information on smokers' adherence to the NRT sample, side effects and safety issues related to the usage. This will improve the design of a large trial to test the effect of the NRT sample.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02491086 . Registered on 7 July 2015.

Economic burden of smoking: a systematic review of direct and indirect costs

BACKGROUND

Smoking imposes considerably high economic costs both on the healthcare system as well as on a country as a whole. This study was aimed at systematically reviewing the currently published literature on the direct and indirect costs associated with smoking globally.

METHODS

A systematic review was performed on systematically searched articles from PubMed and Scopus databases published during the period 1990 to 2014. A combination of key terms such as "economic burden", "direct cost", "indirect cost", and smoking, tobacco or cigarette" and "productivity lost was used for the search. Original research article published in English with the age of study population greater than 35 years, at least three smoking-related diseases and reported direct or indirect cost of smoking were the inclusion criteria.

RESULTS

Fourteen original articles were included in the review. The cost of outpatient care and premature deaths were found to be the most important cost driver of direct and indirect costs respectively. The study showed that smoking-related diseases were responsible for 1.5 - 6.8 % of the national health system expenditures and 0.22-0.88% of GDP of a country.

CONCLUSION

Our review indicated that the costs of smoking are substantial, and smoking have a significant impact on the economy of a country. Policies such as increasing the taxation on a cigarette are required and should be implemented to reduce the economic burden of smoking.

The healthcare costs of secondhand smoke exposure in rural China

OBJECTIVE

The goal of this study was to assess the healthcare costs attributable to secondhand smoke (SHS) exposure among non-smoking adults (age ≥ 19) in rural China.

METHODS

We analysed data from the 2011 National Rural Household Survey which was conducted among adults in five provinces and one municipality in China (N=12,397). Respondents reported their smoking status, health conditions and healthcare expenditures. Relative risks were obtained from published sources. Healthcare costs included annual outpatient and inpatient hospitalisation expenditures for five SHS-related diseases: asthma, breast cancer (female only), heart disease, lung cancer and tuberculosis. SHS-attributable healthcare costs were estimated using a prevalence-based annual cost approach.

FINDINGS

The total healthcare costs of SHS exposure in rural China amounted to $1.2 billion in 2011, including $559 million for outpatient visits and $612.4 million for inpatient hospitalisations. The healthcare costs for women and men were $877.1 million and $294.3 million, respectively. Heart disease was the most costly condition for both women ($701.7 million) and men ($180.6 million). The total healthcare costs of SHS exposure in rural China accounted to 0.3% of China's national healthcare expenditures in 2011. Over one-fifth of the total healthcare costs of SHS exposure in rural China were paid by health insurance. The out-of-pocket expenditures per person accounted for almost half (47%) of their daily income.

CONCLUSIONS

The adverse health effects of SHS exposure result in a large economic burden in China. Tobacco control policies that reduce SHS exposure could have an impact on reducing healthcare costs in China.

Economic burden from smoking-related diseases in Thailand

OBJECTIVE

To assess economic burden attributable to smoking in Thailand in 2009.

METHODS

A prevalence-based, disease-specific cost of illness approach was used to estimate the direct medical costs, indirect medical costs, productivity loss due to premature deaths and absenteeism caused by smoking-related diseases. Direct healthcare costs were obtained from the inpatient and outpatient charge database at the National Health Security Office and the Central Office for Healthcare Information. Indirect healthcare costs were obtained from the Health and Welfare Survey. The household Socioeconomic Survey provided data on income of the population. Costs were estimated for 7 disease groups, namely, lung cancer, chronic obstructive pulmonary disease (COPD), cardiovascular disease (CVD), upper aerodigestive tract cancer, other cancer, other respiratory diseases and other medical conditions. Smoking Attributable Fractions were derived from the 2009 Thai Burden of Disease study.

RESULTS

Total economic burden of smoking amounted to 74.88 billion Thai Baht (THB) (95% CI 74.59 to 75.18) (US$2.18, 95% CI US$2.17 to US$2.19 billion). Of this, most of the burden resulted from productivity loss 62.24 billion THB (95% CI 62.05 to 62.44) (US$1.81, 95% CI US$1.81 to US$1.82 billion). Total medical cost was 12.64 billion THB (12.44 to 12.85) (US$0.37, 95% CI US$0.36 to US$0.37 billion). Excluding other medical conditions, the direct healthcare costs were highest for CVD, followed by COPD and other respiratory diseases, respectively. All together, the total cost of smoking accounted for 0.78% (95% CI 0.78% to 0.79%) of the national gross domestic product and about 18.19% (95% CI 18.12% to 18.27%) of total health expenditure.

CONCLUSIONS

The total economic loss from smoking-related diseases highlights the significant loss to the society, health sector and the country's economy. Such information is crucial for informing national public health policy, particularly when a conflict arises between the economy and health.

Predictors for Smoking Cessation with Acupuncture in a Hong Kong Population

Background. Observational studies of smoking cessation with acupuncture have been reported widely; however, few researchers have focused on its predictors. Objective. This paper attempts to explore the predictors for smoking cessation with acupuncture in a Hong Kong population, aiming to provide references for clinical treatment in the future. Methods. We performed a secondary analysis of data from our observational study “Acupuncture for Smoking Cessation (2011–2014)” in Hong Kong. A total of 23 indexes were selected as possible predictors, and study participants with complete information of 23 indexes were included. By taking 8-week and 52-week smoking cessation results as dependent variables, binary logistic regression method was used to identify the predictors. Additionally, based on an M5P decision-tree algorithm, an equation of “successful rate of smoking cessation with acupuncture” was calculated. Results. (1) 2,051 study participants were included in total. (2) According to the results of binary logistic regression, variables including treatment location, total number of acupuncture sessions received, and whether the study participants received at least 6 sessions of acupuncture were taken as the short-term predictors; gender, treatment location, Fagerstrom Test for Nicotine Dependence (FTND), and total number of acupuncture sessions received were taken as the long-term predictors. (3) According to study participants' FTND, treatment location, and number of cigarettes smoked/day, the equation of “successful rate of smoking cessation with acupuncture” was established. Conclusion. Receiving sufficient and qualified acupuncture is the leading factor for short-term smoking cessation with acupuncture, whereas individual factors and smoking background play a more important role in long-term smoking cessation with acupuncture.

The Economic Impact of Smoking and of Reducing Smoking Prevalence: Review of Evidence

BACKGROUND

Tobacco smoking is the cause of many preventable diseases and premature deaths in the UK and around the world. It poses enormous health- and non-health-related costs to the affected individuals, employers, and the society at large. The World Health Organization (WHO) estimates that, globally, smoking causes over US$500 billion in economic damage each year.

OBJECTIVES

This paper examines global and UK evidence on the economic impact of smoking prevalence and evaluates the effectiveness and cost effectiveness of smoking cessation measures.

STUDY SELECTION

SEARCH METHODS We used two major health care/economic research databases, namely PubMed and the National Institute for Health Research (NIHR) database that contains the British National Health Service (NHS) Economic Evaluation Database; Cochrane Library of systematic reviews in health care and health policy; and other health-care-related bibliographic sources. We also performed hand searching of relevant articles, health reports, and white papers issued by government bodies, international health organizations, and health intervention campaign agencies. SELECTION CRITERIA The paper includes cost-effectiveness studies from medical journals, health reports, and white papers published between 1992 and July 2014, but included only eight relevant studies before 1992. Most of the papers reviewed reported outcomes on smoking prevalence, as well as the direct and indirect costs of smoking and the costs and benefits of smoking cessation interventions. We excluded papers that merely described the effectiveness of an intervention without including economic or cost considerations. We also excluded papers that combine smoking cessation with the reduction in the risk of other diseases. DATA COLLECTION AND ANALYSIS The included studies were assessed against criteria indicated in the Cochrane Reviewers Handbook version 5.0.0. OUTCOMES ASSESSED IN THE REVIEWPrimary outcomes of the selected studies are smoking prevalence, direct and indirect costs of smoking, and the costs and benefits of smoking cessation interventions (eg, "cost per quitter", "cost per life year saved", "cost per quality-adjusted life year gained," "present value" or "net benefits" from smoking cessation, and "cost savings" from personal health care expenditure).

MAIN RESULTS

The main findings of this study are as follows: The costs of smoking can be classified into direct, indirect, and intangible costs. About 15% of the aggregate health care expenditure in high-income countries can be attributed to smoking. In the US, the proportion of health care expenditure attributable to smoking ranges between 6% and 18% across different states. In the UK, the direct costs of smoking to the NHS have been estimated at between £2.7 billion and £5.2 billion, which is equivalent to around 5% of the total NHS budget each year. The economic burden of smoking estimated in terms of GDP reveals that smoking accounts for approximately 0.7% of China's GDP and approximately 1% of US GDP. As part of the indirect (non-health-related) costs of smoking, the total productivity losses caused by smoking each year in the US have been estimated at US$151 billion.The costs of smoking notwithstanding, it produces some potential economic benefits. The economic activities generated from the production and consumption of tobacco provides economic stimulus. It also produces huge tax revenues for most governments, especially in high-income countries, as well as employment in the tobacco industry. Income from the tobacco industry accounts for up to 7.4% of centrally collected government revenue in China. Smoking also yields cost savings in pension payments from the premature death of smokers.Smoking cessation measures could range from pharmacological treatment interventions to policy-based measures, community-based interventions, telecoms, media, and technology (TMT)-based interventions, school-based interventions, and workplace interventions.The cost per life year saved from the use of pharmacological treatment interventions ranged between US$128 and US$1,450 and up to US$4,400 per quality-adjusted life years (QALYs) saved. The use of pharmacotherapies such as varenicline, NRT, and Bupropion, when combined with GP counseling or other behavioral treatment interventions (such as proactive telephone counseling and Web-based delivery), is both clinically effective and cost effective to primary health care providers.Price-based policy measures such as increase in tobacco taxes are unarguably the most effective means of reducing the consumption of tobacco. A 10% tax-induced cigarette price increase anywhere in the world reduces smoking prevalence by between 4% and 8%. Net public benefits from tobacco tax, however, remain positive only when tax rates are between 42.9% and 91.1%. The cost effectiveness ratio of implementing non-price-based smoking cessation legislations (such as smoking restrictions in work places, public places, bans on tobacco advertisement, and raising the legal age of smokers) range from US$2 to US$112 per life year gained (LYG) while reducing smoking prevalence by up to 30%-82% in the long term (over a 50-year period).Smoking cessation classes are known to be most effective among community-based measures, as they could lead to a quit rate of up to 35%, but they usually incur higher costs than other measures such as self-help quit-smoking kits. On average, community pharmacist-based smoking cessation programs yield cost savings to the health system of between US$500 and US$614 per LYG.Advertising media, telecommunications, and other technology-based interventions (such as TV, radio, print, telephone, the Internet, PC, and other electronic media) usually have positive synergistic effects in reducing smoking prevalence especially when combined to deliver smoking cessation messages and counseling support. However, the outcomes on the cost effectiveness of TMT-based measures have been inconsistent, and this made it difficult to attribute results to specific media. The differences in reported cost effectiveness may be partly attributed to varying methodological approaches including varying parametric inputs, differences in national contexts, differences in advertising campaigns tested on different media, and disparate levels of resourcing between campaigns. Due to its universal reach and low implementation costs, online campaign appears to be substantially more cost effective than other media, though it may not be as effective in reducing smoking prevalence.School-based smoking prevalence programs tend to reduce short-term smoking prevalence by between 30% and 70%. Total intervention costs could range from US$16,400 to US$580,000 depending on the scale and scope of intervention. The cost effectiveness of school-based programs show that one could expect a saving of approximately between US$2,000 and US$20,000 per QALY saved due to averted smoking after 2-4 years of follow-up.Workplace-based interventions could represent a sound economic investment to both employers and the society at large, achieving a benefit-cost ratio of up to 8.75 and generating 12-month employer cost savings of between $150 and $540 per nonsmoking employee. Implementing smoke-free workplaces would also produce myriads of new quitters and reduce the amount of cigarette consumption, leading to cost savings in direct medical costs to primary health care providers. Workplace interventions are, however, likely to yield far greater economic benefits over the long term, as reduced prevalence will lead to a healthier and more productive workforce.

CONCLUSIONS

We conclude that the direct costs and externalities to society of smoking far outweigh any benefits that might be accruable at least when considered from the perspective of socially desirable outcomes (ie, in terms of a healthy population and a productive workforce). There are enormous differences in the application and economic measurement of smoking cessation measures across various types of interventions, methodologies, countries, economic settings, and health care systems, and these may have affected the comparability of the results of the studies reviewed. However, on the balance of probabilities, most of the cessation measures reviewed have not only proved effective but also cost effective in delivering the much desired cost savings and net gains to individuals and primary health care providers.

Estimativa da carga do tabagismo no Brasil: mortalidade, morbidade e custos

Os avanços no controle do tabagismo no Brasil podem ser verificados na redução da prevalência nas últimas duas décadas. As estatísticas de óbitos, ocorrência de eventos e custos diretos atribuíveis às doenças tabaco-relacionadas não são estimadas com frequência no país. O objetivo deste artigo foi estimar a carga do tabagismo em 2011, em termos de mortalidade, morbidade e custos da assistência médica das principais doenças tabaco-relacionadas. Desenvolveu-se um modelo econômico baseado em uma microssimulação probabilística de milhares de indivíduos através de coortes hipotéticas que considerou a história natural, os custos diretos em saúde e a qualidade de vida desses indivíduos. O tabagismo foi responsável por 147.072 óbitos, 2,69 milhões anos de vida perdidos, 157.126 infartos agudos do miocárdio, 75.663 acidentes vasculares cerebrais e 63.753 diagnósticos de câncer. O custo para o sistema de saúde foi de R$ 23,37 bilhões. O monitoramento da carga do tabagismo é uma importante estratégica para informar aos tomadores de decisão e fortalecer a política pública de saúde.

Direct and indirect costs of smoking in Vietnam

OBJECTIVE

To estimate the direct and indirect costs of active smoking in Vietnam.

METHOD

A prevalence-based disease-specific cost of illness approach was utilised to calculate the costs related to five smoking-related diseases: lung cancer, cancers of the upper aerodigestive tract, chronic obstructive pulmonary disease, ischaemic heart disease and stroke. Data on healthcare came from an original survey, hospital records and official government statistics. Morbidity and mortality due to smoking combined with the average per capita income were used to calculate the indirect costs of smoking by applying the human capital approach. The smoking-attributable fraction was calculated using the adjusted relative risk values from phase II of the American Cancer Society Cancer Prevention Study (CPS-II). Costs were classified as personal, governmental and health insurance costs.

RESULTS

The total economic cost of smoking in 2011 was estimated at 24 679.9 billion Vietnamese dong (VND), equivalent to US$1173.2 million or approximately 0.97% of the 2011 gross domestic product. The direct costs of inpatient and outpatient care reached 9896.2 billion VND (US$470.4 million) and 2567.2 billion VND (US$122.0 million), respectively. The government's contribution to these costs was 4534.3 billion VND (US$215.5 million), which was equivalent to 5.76% of its 2011 healthcare budget. The indirect costs (productivity loss) due to morbidity and mortality were 2652.9 billion VND (US$126.1 million) and 9563.5 billion VND (US$454.6 million), respectively. These indirect costs represent about 49.5% of the total costs of smoking.

CONCLUSIONS

Tobacco consumption has large negative consequences on the Vietnamese economy.

The burden of smoking in Israel-attributable mortality and costs (2014)

BACKGROUND

Tobacco use is the single most preventable cause of death, incurring huge resource costs in terms of treating morbidity and lost productivity. This paper estimates smoking attributable mortality (SAM) as health costs in 2014 in Israel.

METHODS

Longitudinal data on prevalence of smokers and ex-smokers were combined with diagnostic and gender specific data on Relative Risks (RR) to gender and disease specific population attributable risks (PAR). PAR was then applied to mortality and hospitalization data from 2011, adjusted by population growth to 2014 to calculate SAM and hospitalization days (SAHD) caused by active smoking. These were used as a base for calculating deaths, hospital days and costs attributable to passive smoking, smoking by pregnant women, residential fires and productivity losses based on international literature.

RESULTS

The lagged model estimated active SAM in Israel in 2014 to be 7,025 deaths. Cardio-vascular causes accounted for 45.0% of SAM, malignant neoplasms (39.2%) and respiratory diseases (15.5%). Lung cancer alone accounted for 24.1% of SAM. There were an estimated 793, 17 and 12 deaths from passive smoking, mothers-to-be smoking and residential fires. Total SAM is around 7,847 deaths (95% CI 7,698-7,997) in 2014. We estimated 319,231 active SAHD days (95% CI 313,135-325,326). Respiratory care accounted for around one-half of active SAHD (50.5%). Cardio-Vascular causes for 33.5% and malignant neoplasms (13.2%). Lung cancer only for 4.6%. Total SAHD was around 356,601 days including 36,049 days from passive smoking. Estimated direct acute care costs of 356,601 days in a general hospital amount to around 849 (95% CI 832-865) million NIS ($244 million). Non acute care costs amount to an additional 830 million NIS ($238 million). The total health service costs amount to 1,678 million NIS (95% CI 1,646-1,710) or $482 million, 0.2% of GNP. Productivity losses account for a further 1,909 million NIS ($548 million), giving an overall smoking related cost of 3,587 million NIS (95% CI 3,519-3,656) or $1,030 million, 0.41% of GNP).

CONCLUSIONS

Smoking causes a considerable burden in Israel, both in terms of the expected 7,847 lives lost and the financial costs of around 3.6 million NIS ($1,030 million or 0.42% of GNP).

EPA Guidance on Tobacco Dependence and Strategies for Smoking Cessation in People with Mental Illness

Tobacco dependence is the most common substance use disorder in adults with mental illness. The prevalence rates for tobacco dependence are two to four times higher in these patients than in the general population. Smoking has a strong, negative influence on the life expectancy and quality of life of mental health patients, and remains the leading preventable cause of death in this group. Despite these statistics, in some countries smokers with mental illness are disadvantaged in receiving intervention and support for their tobacco dependence, which is often overlooked or even tolerated. This statement from the European Psychiatric Association (EPA) systematically reviews the current evidence on tobacco dependence and withdrawal in patients with mental illness and their treatment. It provides seven recommendations for the core components of diagnostics and treatment in this patient group. These recommendations concern: (1) the recording process, (2) the timing of the intervention, (3) counselling specificities, (4) proposed treatments, (5) frequency of contact after stopping, (6) follow-up visits and (7) relapse prevention. They aim to help clinicians improve the care, health and well-being of patients suffering from mental illness.

Burden of household environmental tobacco smoke on medical expenditure for Japanese women: a population-based cohort study

BACKGROUND

The economic consequences of environmental tobacco smoke (ETS) have been simulated using models. We examined the individual-level association between ETS exposure and medical costs among Japanese nonsmoking women.

METHODS

This population-based cohort study enrolled women aged 40 to 79 years living in a rural community. ETS exposure in homes at baseline was assessed with a self-administered questionnaire. We then collected health insurance claims data on direct medical expenditures from 1995 through 2007. Using generalized linear models with interaction between ETS exposure level and age stratum, average total monthly expenditure (inpatient plus outpatient care) per capita for nonsmoking women highly exposed and moderately exposed to ETS were compared with expenditures for unexposed women. We performed separate analyses for survivors and nonsurvivors.

RESULTS

We analyzed data from 4870 women. After adjustment for potential confounding factors, survivors aged 70 to 79 who were highly exposed to ETS incurred higher expenditures than those who were not exposed. We found no significant difference in expenditures between moderately exposed and unexposed women. Total expenditures were not significantly associated with ETS exposure among survivors aged 40 to 69 or nonsurvivors of any age stratum.

CONCLUSIONS

We calculated individual-level excess medical expenditures attributable to household exposure to ETS among surviving older women. The findings provide direct evidence of the economic burden of ETS, which is helpful for policymakers who seek to achieve the economically attractive goal of eliminating ETS.

Economic costs attributable to smoking in China: update and an 8-year comparison, 2000-2008

OBJECTIVE

To estimate the health-related economic costs attributable to smoking in China for persons aged 35 and older in 2003 and in 2008 and to compare these costs with the respective results from 2000.

METHODS

A prevalence-based, disease-specific approach was used to estimate smoking-attributable direct and indirect economic costs. The primary data source was the 2003 and 2008 China National Health Services Survey, which contains individual participant's smoking status, healthcare use and expenditures.

RESULTS

The total economic cost of smoking in China amounted to $17.1 billion in 2003 and $28.9 billion in 2008 (both measured in 2008 constant US$). Direct smoking-attributable healthcare costs in 2003 and 2008 were $4.2 billion and $6.2 billion, respectively. Indirect economic costs in 2003 and 2008 were $12.9 billion and $22.7 billion, respectively. Compared to 2000, the direct costs of smoking rose by 72% in 2003 and 154% in 2008, while the indirect costs of smoking rose by 170% in 2003 and 376% in 2008.

CONCLUSIONS

The economic burden of cigarette smoking has increased substantially in China during the past decade and is expected to continue to increase as the national economy and the price of healthcare services grow. Stronger intervention measures against smoking should be taken without delay to reduce the health and financial losses caused by smoking.

The burden of alcohol drinking on co-workers in the Australian workplace

OBJECTIVE

To estimate the cost of the extra time worked by Australian workers due to their co-workers' alcohol drinking.

DESIGN, SETTING AND PARTICIPANTS

A secondary analysis of data obtained from 1677 Australian workers aged 18 years or older collected as part of a broader national study into the third-party harms of alcohol. Computer-assisted telephone interviews were conducted between October and mid December 2008.

MAIN OUTCOME MEASURES

Self-reported measures of the time spent covering for other people at work because of their alcohol drinking; measures of other impacts from co-workers' alcohol drinking; and self-reported income.

RESULTS

Around a third of Australian workers have experienced negative effects from their co-workers' alcohol drinking, with 3.5% of workers reporting having to work extra hours to cover for others. The total annual cost to the Australian economy of this extra work is estimated to be $453 million.

CONCLUSIONS

The results of this study suggest that Australian workers are significantly affected by other people's alcohol drinking, at considerable cost. This finding highlights the significant cost to the workplace of alcohol consumption, extending previous work which has focused only on alcohol-related absenteeism.

Local governments' dependence on tobacco tax revenue: a deterrent to tobacco control in the Republic of Korea

OBJECTIVE

To investigate, in the Republic of Korea, whether local governments' participation in an anti-smoking programme supported by the National Health Promotion Fund in 2002-2003 was related to the percentage of local tax revenue comprised by the tobacco consumption tax (TCT).

METHODS

Using financial and administrative data on 163 municipalities, the authors estimated logit models of local governments' participation in the anti-smoking programme as a function of the proportion of local tax revenue that came from the TCT and a set of control variables, namely local socioeconomic characteristics and the size of the staff in the local public health centre (PHC).

FINDINGS

Local governments that derived a greater percentage of their local tax revenue from the TCT, particularly those that ranked in the upper fourth in terms of this percentage, were less likely to participate in the anti-smoking programme. Insufficient staff in the PHC was also found to be associated with lower participation in the anti-smoking programme.

CONCLUSION

Local governments' dependence on revenue from the TCT may be a deterrent to tobacco control in the Republic of Korea.

The impact of smoking and quitting on household expenditure patterns and medical care costs in China

BACKGROUND

Smoking remains very common in Chinese men, and the economic burden caused by cigarette consumption on smokers and their families may be substantial. Using a large nationally representative household survey, the third National Health Services Survey (NHSS, 2003), we estimated the economic impact of smoking on households.

METHODS

Smoking status of all household members (over 15 years) was collected by interview for the NHSS, and households classified into one of seven categories based on their smoking status. Information on household income and expenditure, and use of health services was also obtained. We assessed both the "direct" costs (reducing funds available for spending on other commodities such as food, education, medical care, etc, using a fractional logit model), and "indirect costs" (increasing medical expenditures, using a log-linear model).

RESULTS

Every five packets of cigarettes consumed per capita per month reduces household spending on other commodities, most notably on education (by about 17 yuan per capita per annum) and medical care (11 yuan). The effects are greatest among low-income rural households. Households with quitters spend substantially more on medical care than never-smoking households (64 yuan for households with two or more quitters).

CONCLUSIONS

If a household member smokes, there is less money available for commodities such as education and medical care. Medical care expenditure is substantially higher among households with quitters, as ill-health is the main reason for quitting smoking in China. Smoking impoverishes a substantial number of poorer rural households.

Does smoking affect hospital use before death? A comparison of ever- and never-smokers in the last years of life

BACKGROUND

Given the apparent greater use of health care services by smokers and predictions of higher costs for a never-smoking population, we aimed in this study to determine whether the acute hospital costs in the last years of life of never- and ever-smokers differed before death using a database of the decedents in 1 year in Hong Kong.

OBJECTIVES

To compare the acute hospital use of ever- and never-smoker decedents.

METHODS

The data on cause of death, personal characteristics, and public hospital discharges were linked for all decedents in 1998 in Hong Kong. The incidence rate ratio was used to compare, for ever- and never-smokers, the number of days spent in an acute hospital over the prior 7 years. Analyses were done using specific and all cause mortality, adjusted for sex, lifestyle factors, and life expectancy.

RESULTS

Compared with never-smokers who died of the same condition, ever-smokers who died of chronic obstructive pulmonary disease used 28% more acute hospital bed days and those dying of smoking-related cancer 9% fewer. These differences cancelled out over the case-mix of deaths with no net difference in acute bed day use by smoking status for all-cause mortality.

CONCLUSIONS

There was no difference in acute hospital bed days in the last years of life of ever- and never-smokers but some differences by cause of death. Reducing smoking in this population will not increase acute hospital use.

The costs of smoking in Vietnam: the case of inpatient care

OBJECTIVE

To estimate the social costs of smoking related to inpatient care in Vietnam using 2005 data.

DESIGN

The cost of illness as a result of hospitalisation for three major smoking-related diseases combined with the prevalence-based approach to obtain the costs of smoking in Vietnam for inpatient care.

MAIN OUTCOME MEASURE

Smoking-attributable costs of inpatient care for lung cancer, chronic obstructive pulmonary disease (COPD), and ischaemic heart disease.

RESULTS

The total cost of inpatient health care caused by smoking in Vietnam reached at least 1 161 829 million Vietnamese dollars ($VN) (or $US 77.5 million) in 2005. This represents about 0.22% of Vietnam gross domestic product (GDP) and 4.3% of total healthcare expenditure. The majority of these expenses are related to COPD treatment ($VN 1,033541 million or $US 68.9 million per year) followed by lung cancer ($VN 78,143 million, or $US 5.2 million per year) and ischaemic disease ($VN 50,145 million, or $US 3.3 million per year). The government directly finances about 51% of these costs. The rest is financed either by households (34%) or by the insurance sector (15%).

CONCLUSIONS

The social costs of smoking in Vietnam as the percentage of GDP is lower compared to estimates from high-income countries. The true costs would be substantially higher if all smoking-related diseases, outpatient care and mortality-related costs are included. More research is needed to augment the estimates presented in this paper.

Disease burden of adult lung cancer and ischaemic heart disease from passive tobacco smoking in China

OBJECTIVE

To address the health hazards tobacco smoking imposes upon non-smokers in China, this paper estimates the burden of diseases in adults from passive tobacco smoking for two major diseases--lung cancer and ischaemic heart disease (IHD).

METHODS

The disease burden was estimated in terms of both premature mortality and disability adjusted life years (DALYs), a measure that accounts for both the age at death and the severity of the morbidity.

RESULTS

Passive smoking caused more than 22,000 lung cancer deaths in 2002 according to these estimates. When the toll of disability is added to that of mortality, passive smoking was responsible for the loss of nearly 230,000 years of healthy life from lung cancer. Using the evidence from other countries that links IHD to passive smoking, we estimated that approximately 33,800 IHD deaths could be attributable to passive smoking in China in 2002. Passive smoking is also responsible for the loss of more than one quarter of a million years of healthy life from IHD. Although most of the disease burden caused by active smoking occurs among men, women bear nearly 80% of the total burden from passive smoking. The number of deaths among women caused by passive smoking is about two-thirds of that caused by smoking for the two diseases we examined.

CONCLUSION

Even without considering the passive smoking risks for other diseases and among children that have been documented in other countries, passive smoking poses serious health hazards for non-smokers, especially for adult female non-smokers in China, adding more urgency to the need for measures to be taken immediately to protect the health of non-smokers and curb the nation's tobacco epidemic.

The crowding-out effects of tobacco and alcohol where expenditure shares are low: analyzing expenditure data for Taiwan

In this paper, we used data from the 2004 Survey of Family Income & Expenditure of Taiwan to show that the problem of the crowding-out effects of tobacco and alcohol in a country with low expenditure can still be serious. Most studies that have investigated this issue have focused on developing countries with a high expenditure share on tobacco or alcohol, and have often overlooked the effects in countries with a low expenditure on such goods. After controlling for the endogeneity of tobacco and alcohol expenditure, and the possibility that households with a zero expenditure on tobacco and alcohol may result from a corner solution rather than abstention, we found that the lowest income households are still most vulnerable to tobacco and alcohol expenditures despite an overall low expenditure in Taiwan. Even higher income households may suffer a lower standard of living due to such expenditure. In addition, some goods and services may be perceived differently by households with different levels of income and this may be caused by the difference in composition across broad expenditure categories. Our results suggest that the government ought to tackle the problem of smoking and drinking outside the realm of health, since these expenditures may harm the country's standard of living even when there is high income.