Health Services Research Fund & Health Care and Promotion Fund: Research Dissemination Reports (Series 2)published_or_final_versio

Chau, J

Cheung, WL

Hedley, AJ

Ho, LM

Ho, SY

McGhee, SM

Pow, MA

Hong Kong Medical Journal

HKU Scholars Hub

Title The cost of tobacco-related diseaseAuthor(s) McGhee, SM; Chau, J; Cheung, WL; Ho, LM; Ho, SY; Pow, MA;Hedley, AJCitation Hong Kong Medical Journal, 2006, v. 12 n. 4 Suppl 2, p. S32-S35Issued Date 2006URL http://hdl.handle.net/10722/57360Rights Hong Kong Medical Journal. Copyright © Hong Kong MedicalAssociation.32      Hong Kong Med J Vol 12 No 4 Supplement 2 August 2006SM McGhee  J Chau  WL Cheung  LM Ho  SY Ho  M Pow  AJ Hedley  HEALTH SERVICES RESEARCH FUND – HEALTH CARE AND PROMOTION FUNDHong Kong Med J 2006;12 (Suppl 2):S32-5The cost of tobacco-related disease○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○Department of Community Medicine, TheUniversity of Hong KongSM McGhee, J Chau, A Cheung, LM Ho, DHo, M Pow, AJ HedleyHCPF project number: 212919Principal applicant and corresponding author:Dr SM McGheeDepartment of Community Medicine, TheUniversity of Hong Kong, 5/F William MWMong Block, Faculty of Medicine Building,21 Sassoon Road, Pokfulam, Hong KongSAR, ChinaTel: (852) 2819 9193Fax: (852) 2855 9528E-mail: smmcghee@hkucc.hku.hkBackgroundThere is growing epidemiological evidence of the harm caused to health bytobacco smoking. The data can be used to calculate the economic impact oftobacco use. In Hong Kong, information is available on the impact of tobaccouse on mortality and also on the impact of passive smoking on health careutilisation and on time taken off work by those exposed to second-hand smoke(SHS). Using this and other data we calculated the annual health-related cost oftobacco smoking, with 1998 as the example year.AimThis study aimed to estimate the costs of tobacco-related disease in 1998 usinglocal data.MethodsThis study was conducted from May 2000 to May 2003.DataData were used to estimate the cost of in-patient and out-patient use of healthcare, in both public and private sectors, which could be related to tobacco use.This covered the effects of both active and passive smoking.The datasets used included: the lifestyle and mortality study (LIMOR), whichprovided relative risks of active and passive smoking on mortality from a varietyof causes1; the Harvard Household Survey (HHS), which provided populationdata on active and passive smoking and on health care utilisation2; the PoliceHealth Survey (PHS), which provided data on the association between passivesmoking and health care utilisation and time off work3; and the HospitalAuthority (HA) in-patient database, which covers all episodes of hospital care inpublic hospitals.Mortality due to active smokingAnalysis of the LIMOR dataset indicated the risks of excess mortality fromspecific causes for smokers.4 The dataset was reanalysed to calculate the fractionof deaths attributed to active smoking. Applying these attributable fractions toall deaths, we estimated the number of lives lost, premature lives lost (ie those<75 years), and lives lost during productive years (ie those <65 years). Using theage at death, we calculated life years lost before age 75 and productive yearslost. Life years were discounted at 3% per annum. The losses were monetised byvaluing a premature life lost at HK$10 million and a working year lost at themedian wage in 1998 for male or female, as appropriate.Morbidity due to active smokingWe applied the disease-specific attributable fractions for mortality to hospitaladmissions, assuming that the proportion of all those who died of a specificdisease was similar to the proportion of all those admitted for that disease.Specialist out-patient visits were analysed in a similar manner. The HAprovided data on the unit cost of a bed-day in acute and long-stay hospitals andunit costs of a specialist out-patient visit. For private hospitals, we used dataon the number of admissions. BUPA (Asia) Ltd supplied an estimate of chargesfor admissions that gave a conservative estimate of the cost of private hospitalcare.Key Messages1. Tobacco use costs Hong Kongmore than $5.3 billion (bn) peryear (estimated from 1998 data).2. Two thirds of the cost ($3.6 bn)was for health care and theremainder ($1.8 bn) was forproductivity losses due to illhealth or death during workinglife. The proportion of themorbidity costs which fell on thepublic sector was 70% for activesmoking and 50% for passivesmoking.3. Much of the enormous annualcost  f rom tobacco use isavoidable.4. Legislation preventing smokingin public places would reducemuch of the expenditure onpassive and some of that onactive smoking effects.Hong Kong Med J Vol 12 No 4 Supplement 2 August 2006      33Cost of tobacco-related diseaseLess severe morbidity could be treated by generalout-patient clinics (GOPCs), Accident and Emergency(A&E) units, or by private general practitioners (GPs). ForGOPCs, we applied the attributable risks calculated fromLIMOR to the total number of GOPC visits and multipliedthe value obtained by the unit cost of a visit. For private GPvisits, we included only visits for respiratory disease andused an estimate of relative risk for a smoker from a localstudy.5 This relative risk was applied to an estimate of allvisits for respiratory problems and the average cost of thesevisits taken from the HHS.The relative risk of taking extra time off work due toactive smoking was estimated using the PHS data. Anattributable fraction was then applied to a conservativeestimate of the days taken off work by the workingpopulation and the days lost were valued at the medianwage. Similarly, the days spent in hospital as an in-patientby those of working age was adjusted to reflect the non-working population and multiplied by the median wage.Those who suffer from tobacco-related diseases may useother services such as long-term care, that is residential careincluding nursing homes or may be looked after at home bya domestic helper or family members. We estimated thesecosts based on the number of smoking attributable cases ofdisease identified. The number of persons enrolled in thefour types of residential care home was obtained fromroutine data (personal communication). The unit monthlycost for each kind of residential care home (personalcommunication) was multiplied by the attributable numberof cases to get the annual smoking attributable nursing homecost. We used the amount of time over which personsrequired home-based care from the LIMOR dataset andapplied it to the costs of local and foreign domestic helpers6to calculate the attributable cost for decedents in their lastyear of life. We did not attribute any cost to those lookedafter by family members due to the lack of suitable costdata.Mortality due to passive smokingPassive smoking has been associated with lung cancer,chronic obstructive pulmonary disease (COPD), ischaemicheart disease (IHD), and stroke in both local andinternational studies. We used the locally derived relativerisks for lung cancer, COPD, and stroke and the overseaspooled results for IHD, which were very similar to the localfindings. We estimated attributable fractions of mortalityfrom these causes and valued them in dollars in the sameway as for active smoking. In the main estimate of cost, weincluded the impact of passive smoking at home and atwork. The costs were calculated for all non-smokers.Morbidity due to passive smokingLocal data on the costs in the first year of life due topre- and post-natal passive smoke exposure are available.7From another local study on 8- to 12-year-old children,8we extrapolated the excess doctor visits caused by passivesmoking and their costs to children between 1 to 15 yearsold. Local data on the levels of the nicotine metabolitecotinine in catering workers has been used to model thelikely mortality from lung cancer and heart disease in thisoccupational group.9 For the remainder of the population,we applied the attributable fractions for mortality toadmissions for lung cancer, COPD, IHD, and stroke. Wedid not include the cost of private hospitals due to lack ofdata.For more minor morbidity, we used local data onself-reported use of GP services and their costs for thoseexposed to SHS at work.10 We could not include the impactof SHS at home due to insufficient data.We estimated time lost due to passive smoking from apublished paper11 using the PHS dataset, but recalculated itto give sex-specific estimates. We also included an estimateof the time lost due to the attributable inpatient admissionsfor the working population.All reported costs are in Hong Kong dollars(HK$7.8=US$1.0) and are for 1 year (1998).ResultsThe Table shows the costs of active and passive smoking.We estimate that 5596 deaths (aged ≥35 years) in HongKong in 1998 were attributable to active smoking and 3398(61%) of these are premature deaths (<75 years). Thenumber of deaths occurring while smokers or ex-smokerswere in their productive years (<65 years) was 1529 (27%of all attributable deaths).The smoking-attributable years of potential life lost forall premature deaths was 28 668 years with a 3% discountrate. This is 8.4 years for each smoking-attributablepremature death. Assuming that the production of a personnot in the work force is zero, the attributable productive yearslost was 8669 person years with a 3% discount rate.Value of mortality attributable to active smokingApplying the value of $10 million to each premature lifelost, we obtain a value of $33 980 million. The monetaryvalue of the lost productive years was $1244 million,valued at the median wage.Morbidity due to active smokingThe smoking-attributable cost of public acute and long-stayhospital care was $1314 million. This was about 5% of theHA’s total expenditure in 1998.The estimated annual cost of private hospital utilisationattributable to active smoking was $124 million.Smoking-attributable visits to an HA specialist out-patient clinic (SOPC) numbered 256 823 with a cost of $148McGhee et al34      Hong Kong Med J Vol 12 No 4 Supplement 2 August 2006million, representing 5.2% of all visits to non-paediatricSOPCs.The cost of the 714 585 attributable attendances atGOPCs was estimated to be $160 million; this was 11.7%of the total cost for GOPC visits in 1998. If we assumethat the average public sector doctor sees 30 patients a day5 days a week for 48 weeks per year, then the smoking-attributable visits represent the workload of 99 full-timedoctors in GOPCs.There were 105 661 smoking-attributable visits to A&Eunits costing $60 million. This amounts to 4.6% of the totalA&E visits in 1998.The cost of the 519 962 attributable GP consultationsfor respiratory disease in 1998 was $94 million. Theattributable visits were 2.9% of total doctor consultationsfor respiratory disease in 1998. If we assume each GP sees30 patients per day 5 days a week for 48 weeks per year,these consultations are equivalent to the workload of 72full-time GPs.Absence for illness or injury due to active smokingnumber was estimated to be 192 503 days. Of these, 116 590days may be due to admissions into public hospitals.Valued at the median monthly wage, this was $74 million.This did not include the cost of time off for doctorconsultations or a period of suboptimal productivity onreturn to work.The attributable cost of nursing home care due to activesmoking was $913 million while the cost of home-basedcare was $5 million.Morbidity due to passive smokingExtra hospitalisations and out-patient consultations dueto SHS exposure in utero and post-natally at homeresulted in an annual cost of $27.1 million.7 Extrapolatingthis number to all children aged 1 to 15 in Hong Konggave an estimate of $6.2 million for extra doctor visits forchildren.Public hospital use for lung cancer, COPD, IHD, andstroke attributable to passive smoking costed a total of $471million for home or work exposure.For the three million full-time workers, there wereTable.  Summary of the annual costs (1998) of mortality and morbidity due to diseases caused by tobaccoComponent of cost No. of smoking Unit cost (HK$) Valueattributable units (million HK$)Active Passive Active smoking Passive smoking Active Passivesmoking smoking smoking smokingMortalityTotal lives lost 5596 1324 - - - -Premature deaths (<75 years) 3398 529 10 million 10 million 33 980 5290Productive lives lost (<65 years) 1529 178 - - - -Life years lost (<75 years) 28 668 3719 - - - -Productive years lost (<65 years) 8669 815 male: 144 000, male: 144 000, 1244 109female: 108 000 female: 108 000MorbidityAdmissions and outpatient use in children - 33Public hospital daysAcute 270 038 88 916 3744 3744 1011 333Long stay 152 888 69 588 1985 1985 303 138Private hospital episodes 6370 NE* 19 500 on NE 124 -averageSpecialist out-patient clinics (visits) 256 823 NE 578 NE 148 -General out-patient clinics (visits) 714 585 NE DH: 218, NE 160 -HA†: 265Accident & emergency (visits) 105 661 NE 572 NE 60 -Private general practitioner (visits) 519 962 approx 181 181 94 2481 500 000Days off work (private sector) 170 893 942 409 male: 395, male: 395, 66 319Days off work (public sector) 21 610 102 390 female: 296 female: 296 8 35Nursing home care 913 -Home-based care 5 2Sub-total component of cost Active smoking Passive smokingHealth care HK$1 900 000 000 HK$752 000 000Residential and informal care HK$918 000 000 HK$2 000 000Lost working time HK$1 310 000 000 HK$463 000 000Deaths (all ages) 5596 1324Deaths (<75 years) 3398 529Sub-total annual costs HK$4.1 billion plus the value of lives lost HK$1.2 billion plus the value of lives lostTotal annual costs HK$5.3 billion plus the value of lives lost of 6920 (3927 of them premature) deaths* NE denotes not estimated† DH denotes Department of Health, and HA Hospital AuthorityHong Kong Med J Vol 12 No 4 Supplement 2 August 2006      35Cost of tobacco-related diseasearound 1.5 million extra visits to a doctor for cold, flu, orfever, which were attributable to SHS exposure at work.The cost was $248 million with $21 million (8.5%)attributed to the public sector, $71 million (28.6%) paidfor by the employer, and $156 million (62.9%) paid by theemployees themselves. We do not have data for homeexposure effects on GP visits.After applying the population attributable fraction tothe total number of days off, we estimate an attributableloss of 1 044 799 days per year. Applying the median salary,exposure to SHS at work for the labour force in 1998 cost$354 million. The value of attributable work days lost dueto hospital admissions amounted to $7.2 million for SHSexposure at home or at work.The attributable cost of home-based care due to passivesmoking was $2 million but we could not estimate the costof nursing home care for conditions caused by passivesmoking.ConclusionsA conservative estimate of the cost of smoking in HongKong in 1998 is $3.6 billion for health care and $1.8billion for productivity losses. About 3927 people diedprematurely in that year. Of the morbidity costs, 70% and50% for active and passive smoking respectively wereincurred in the public sector. About 23% of the totalannual costs is due to passive, rather than active, smoking.Of the productivity losses, 26% was due to passivesmoking with most of this effect likely to be due to passivesmoking at work. This costing has not included the costof intensive care or coronary care, or pain and sufferingdue to illness.AcknowledgementsThis study was supported by the Health Care andPromotion Fund (#212919). The authors thank the HA,Department of Health, and BUPA (Asia) Ltd for access todata; Ms Patsy Chau and Ms Dorothy Lam for help with theanalyses; Ms Manda Tsang for literature review; and ProfTH Lam for helpful guidance.References1. Mortality and smoking in Hong Kong: a death registry basedcase-control study. Dissemination report. Hong Kong: HealthServices Research Committee; 2000 December. Report No.: 631012.2. Harvard Household Report 1998. A report prepared for HarvardUniversity by the Health Services Research Group, Department ofCommunity Medicine and the Social Sciences Research Centre,University of Hong Kong.3. Lam TH, Ho LM, Hedley AJ, et al. Environmental tobacco smoke ex-posure among police officers in Hong Kong. JAMA 2000;284:756-63.4. Lam TH, Ho SY, Hedley AJ, Mak KH, Peto R. Mortality and smokingin Hong Kong: case-control study of all adult deaths in 1998. BMJ2001;323:361.5. Wun YT, Wong TW, Tam W, Yu TS. Patient characteristics ofencounters in general practice. Hong Kong Pract 2002;24:59-65.6. Hong Kong Labour Department website: http://www.labour.gov.hk/eng/plan/iwFDH.htm. Accessed in January 2005.7. Leung GM, Ho LM, Lam TH. The economic burden of environmentaltobacco smoke in the first year of life. Arch Dis Chil 2003;88:767-71.8. Peters J, McCabe CJ, Hedley AJ, Lam TH, Wong CM. Economicburden of environmental tobacco smoke on Hong Kong families:scale and impact. J Epidemiol Community Health 1998;52:53-8.9. Hedley AJ, McGhee SM, Repace J, et al. Passive smoking and risksfor heart disease and cancer in Hong Kong catering workers. HongKong Council on Smoking and Health; 2001 May. Report No.: 8.10. McGhee SM, Hedley AJ, Ho LM. Passive smoking and its impact onemployers and employees in Hong Kong. Occup Environ Med 2002;59:842-6.11. McGhee SM, Adab P, Hedley AJ, et al. Passive smoking at work: theshort-term cost. J Epidemiol Community Health 2000;54:673-6.

The cost of tobacco-related disease

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The cost of tobacco-related disease

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