Background
The common argument used against the implementation of tobacco control policies is that revenue from tobacco duty is considerably higher than the health care costs smoking imposes on society. This point is true as revenue in the United Kingdom (UK) totalled £9.1 billion while recent costs estimates for the treatment of smoking-attributable disease totalled £5.2 billion to the UK National Health Service. However, this argument becomes unclear when indirect costs such as productivity loss or cost of absenteeism are incorporated. In the UK, there were 29.2 million employed adults in 2011 of which 20% were current smokers. This equates to approximately 5.84 million employed adult smokers. There are currently no studies which have quantified the economic impact of smoking-attributable indirect costs to both employers and the wider society in the UK. These costs are suspected to impose a large economic burden to society but the best practice methodology for estimating indirect costs and the magnitude of these costs are still unknown. Therefore, the aims of this thesis were to quantify the economic impact of smoking-attributable indirect costs due to productivity loss from premature mortality and absenteeism of workforce and to evaluate workplace interventions which could potentially decrease the burden of smoking in the workforce in the UK.
Methods
A number of methods were used along with a range of data sources which provided the information to quantify the economic impact of smoking in the workforce. Cost-of-illness methodology based on the human capital method was utilised to quantify the monetary burden of smoking in the workforce due to premature mortality in the UK. Systematic review and meta-analysis was used to examine the epidemiological association between smoking and absenteeism while also providing the necessary parameters to estimate costs of absence in the UK. Finally, decision analysis and Markov simulation modelling was used to conduct both cost-benefit analysis and cost-effectiveness analysis from the employer's perspective for evaluating workplace smoking cessation interventions of brief advice, individual counselling and nicotine replacement therapy with individual counselling.
Results
Cost-of-smoking modelling estimated that smoking was responsible for 96,105 deaths (58% male) in adults aged 35 years and over (17% of all deaths) in the UK annually, resulting in 1.2 million years of total life lost and 357,831 years of productive life lost valued at £4.93 billion in 2010. From the systematic review of 29 longitudinal studies, current smokers had a 33% increase in risk of absenteeism and were absent for an average of 2.74 more days per year compared with non-smokers. Compared with never smokers, ex-smokers had a 14% increase in risk of absenteeism; however, no increase in duration of absence could be detected. Indirect comparison meta-analysis showed that current smokers also had a 19% increase in risk of absenteeism compared with ex-smokers. Consequently, smoking was estimated to cost UK employers £1.46 billion in 2011 from absenteeism in the workplace.
Workplace interventions for smoking cessation provide a possible method for reducing the burden of smoking in the workforce. Cost-benefit analysis of workplace interventions resulted in brief advice being the optimal decision strategy for women while brief advice and individual counselling both were optimal decision strategies for men in terms of minimising total costs and maximising return on investment for the employer. If the employer valued maximising quitting instead, cost-effectiveness analysis showed that nicotine replacement therapy with individual counselling would be the optimal strategy given a maximised budget constraint.
Conclusion
This thesis has provided the first indirect cost-of-smoking study quantifying the productivity loss due to premature mortality and absenteeism in UK; the first systematic review and meta-analysis which has explored the association between smoking and absence from work; and the first cost-benefit and cost-effectiveness analyses of workplace interventions for smoking cessation in the UK. The implications of this research have particular relevance for UK policy makers and employers to justify stronger tobacco control policy which promotes smoking cessation. However, these findings are not unique to the UK. The thesis has provided the framework and methodology for studies that can strengthen the evidence-base around the economics of smoking in other countries as well
