Economic Burden Attributable to Smoking in China ——A new estimate based on national-wide data

**Economic Burden Attributable to Smoking in ChinaA new estimate based on national-wide dataSichuan University Zhengzhong MaoLijiang Yunnan 2011.10

ContentsBackgroundEstimation MethodEstimated ResultDiscussion

Background1There are more than 300 million current smokers in China. However, 61% of Chinese adults believe that smoking does not cause serious harm, and 74.0% of ever smokers declared no intention to quit smoking.

Economic burden attributable to smoking is one of the most common indexes to measure adverse effects of tobacco use; persistent tobacco control campaign needs updated information about smoking cost **

Background2Literature Review of Economic Burden Attributable to Smoking in China** (total economic attributable to smoking )

AuthorYear CostChen et al19882.3 billion RMB (280 million US dollars( only medical costs attributable to smoking)Jin et al198927.1 billion RMB3. 3 billion US dollars(total economic burden attributable to smoking )Sung et al200041 billion RMB 5 billion US dollars (total economic attributable to smoking )LI et al2005252.67286.06 billion RMB3641 billion US dollars

.Estimation Method**Smoking Attributable Fraction (SAF)Indirect Disease Cost

Data SourcesRelated Population and Diseases

1. Data SourcesThe data of smoking rate, inpatient and outpatient service cost, and absence on leave, etc were derived from the family health questionnaire of 3rd (in 2003) and 4th (in 2008) national health service survey (NHSS)Smoking related disease mortality relative risk (RR) was derived from study result by GU Dongfeng, etc (GU and Kelly et al, 2009, NEW ENGL J MED) RemarksNo differentiation between previous smoker and current smoker during calculation, that is, the smoking status only is divided into smoker and non-smoker.**

2.Related Population and DiseasesPopulation: aged 35+Three categories of smoking-related diseases Cancer (ICD10C00C97) Cardiovascular Diseases (ICD10I00I99) Respiratory Diseases (ICD10J00J99)**

**3. Smoking-attributable Fraction (SAF)PN : prevalence rate of never smokers;PS : prevalence rate of smokers;RR : relative risk of mortality for smokers compared to never smokers.I disease category ;Rrural or urban;S : gender;A : age group: 35~64 , or 65+.(1)SAF estimates the proportion of medical service attributable to smoking.

**4. Direct Medical Cost SAEirsa = [PHirsa QHirsa + PVirsa QVirsa 26 + PMirsa x QMirsa x 26] POPrsa SAFirsa (2) PH: average expenditure per inpatient hospitalization;QH :average number of inpatient hospitalizations per person in 12 months;PV: average expenditure per outpatient visit;QV: average number of outpatient visits per person in two weeks;PM :average medication expenditures per person with positive self-medication expenditures in two weeks;QM :proportion of persons with positive self-medication expenditures in two weeks;POP: population in 2003 or 2008 ;Subscriptions I, r, s and a have the same meaning as formula (1).

**5. Indirect Medical Cost SAIirsa = [PHIirsa QHirsa PVIirsa QVirsa 26 + IDAYirsa Ersa Yr] POPrsa SAFirsa PHI: average expenditures for transportation, nutritious supplemental food, and caregivers per inpatient hospitalization PVI: average expenditures for transportation per outpatient visitIDAY: average number of annual inpatient days due to treating disease category i per employed person E proportion of the total population that is currently employed Y daily earnings in 2003 or 2008. Subscriptions have the same meaning as formula (1)

**6. Indirect mortality costsSADirsa= [DRATEirsa POPrsa] SAFirsa SAYPLLirsa= SADirsa LErsa PVLErsa = SAMCirsa= SADirsa PVLErsaDRATE : mortality per 100,000 personsLE: average number of years of life expectancy remaining at the age of deathSURV(m): probability that a person will survive to age mmaxa : the oldest age group (e.g., age 85+)Y(m) : mean annual earnings of an employed person at age mE(m) : proportion of the population of age m that is employed in the labor marketg : growth rate of labor productivityV : discount ratea: age at deathSubscription has same meaning with formula (1)

.Estimated Result**5. Comparison Among 3 Study Results 4. Economic Burden Attributable to Smoking 3. Years of Potential life lost2. Smoking-attributable Fraction (SAF)1. smoking prevalence rate

1. smoking prevalence rate**Table 1. Smoking Rate of Adult aged 35 years old and above in China(%) (National Health Service Survey Data)

20032008Total33.131.4Female in Rural Area4.64.5 35~64 4.03.9 65+ 7.87.2Female in City5.34.7 35~64 3.53.7 65+10.77.4Male in Rural Area6461.3 35~6465.262.9 65+58.054.0Male in City56.153.0 35~64 60.358.1 65+42.337.1

**2. Smoking-Attributable Fraction (SAF)Table 2. Disease-specific relative risk of mortality for smokers and smoking-attributable fractions (SAFs) in China, 2008, age for adults aged 35 and older* Source: Gu and Kelly et al. (2009)

RR*SAF (%)UrbanRuralMaleFemaleMaleFemaleMaleFemale35~6465+35~6465+35~6465+35~6465+Respiratory diseases 1.11.437.524.931.573.088.097.031.653.00 Cardiovascular diseases1.21.218.995.930.771.539.668.410.811.49Cancer1.61.6224.2216.952.244.3925.722.92.364.27

**3. Years of potential life lostTable 3. Number of deaths and years of potential life lost (YPLLs ) attributable to smoking in China, 2008, among adults aged 35 and older

DeathsYPLLsMale495,0537,785,011Female57,227720,60935~64 215,9945,340,08765+ 336,2863,165,533Urban154,7452,396,498Rural397,5356,109,122Respiratory diseases61,514628,559Cardiovascular diseases147,7921,882,707Cancer342,9745,994,354Total 552,2808,505,620

**4. Economic Burden Attributable to Smoking Table 4. Economic costs of smoking in China, 2008, for adults of age 35 and older (Unit: US $100 million)

Sheet1

Direct medical costSubtotalIndirect costSubtotalTotal

OutpatientInpatientindirect morbidity costIndirect mortality costs

transportation and caregiversAbsence from work

Male40.514.855.43.32.3207.8213.4268.7

Female4.91.86.60.50.412.313.119.8

35~6424.59.934.42.52.2202.0206.7241.1

65+20.96.827.61.30.418.019.847.4

Urban20.08.428.41.40.7104.7106.8135.1

Rural25.48.333.72.51.9115.3119.7153.4

Respiratory diseases7.61.79.30.81.18.310.219.6

Cardiovascular diseases21.87.329.11.71.140.142.972.0

Cancer16.07.623.61.40.4171.6173.4197.0

Total45.416.662.03.82.6220.0226.5288.5

**5. Comparison Among 3 Study Results* Table 5. Comparison of smoking-attributable deaths, years of potential life lost, and economic costs in 2000, 2003, and 2008 ($100 million, in 2008 price)* All 3 study data were derived from National Health Service Survey.

Sheet1

200020032008Percentage Change(%)Percentage Change (%)

2000 - 20032000 - 2008

Mortality688,512574,107552,280-16.62-19.79

YPLL9,699,2518,162,7718,505,620-15.84-12.31

Direct costs24.442.062.072.07154.19

Outpatient visits12.924.745.492.31253.04

Inpatient hospitalization9.46.516.6-30.3677.56

Self-medication2.210.7392.57

Indirect costs47.6128.7226.5170.34375.75

Transportation and caregivers1.81.53.8-14.74118.81

Absence from work3.91.62.6-58.81-32.24

Mortality42.0125.6220.0199.19424.07

Total72.0170.1288.5137.04300.68

Economic Burden of smoking-related Lung Cancer per case: Ad hoc Survey (2009)Sample size= 650 patients with lung cancer ; available sample: 618 in which there were 396 smokers. The proportion of smoker was 64.08%. ($1.00= RMB6.80)

ItemsAmountRMB )Ratio Direct Medical Cost67430.0156.77% Indirect Medical Cost2596.232.19%Direct Economic Burden70026.2458.96%Indirect Economic Burden48744.3241.04%Total Economic Burden118770.56 ($17466.3)100%

Total Lung Cancer Economic Burden attributable to Smoking The ratio of smokers among lung cancer patients is derived from this survey . Lung cancer morbidity is cited from paper Survey of Lung Cancer Morbidity among Population of Different Age published in Southwest Defensive Medicine (1st, 2004)

ItemAmount Lung Cancer Patient10 thousand68.6Smoker Proportion among Lung Cancer Patient 64.08%Smokers among Lung Cancer Patient 10 thousand43.96Cost of treating Lung Cancer (Yuan/ Case)118770.56Predicted total Economic Burden of Lung Cancer attributable to smoking (100 million Yuan) 522.12Almost Equivalent to 7.67 8 billion US dollars

.Discussion (1)Overall economic burden attributable to smoking in 2008 was 28.85 billion US dollars, accounting for 2% total health expenditure in China . Economic burden attributable to smoking by male is the dominant component of the total loss, accounting for 93.1%.

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.Discussion (2)Changes brought by economic burden attributable to smoking in past 8 years**+The indirect death cost in 2003 and 2008 was a 199.2% increase and 427.1% than that in 2000, respectively. The major factor lays in distinct increase of labor force cost (individual income in city and rural area were 2 times and 1.1 times than that in 2000, respectively; individual income in city and rural area were 3 times and 2 times than that in 2000, respectively) Compared with 2000, direct medical cost in 2003 and 2008 increased 72% and 154, respectively.

.Discussion (3)The estimates for the costs of smoking may be under-estimated for several reasons Economic burden brought by passive smoking wasnt taken into consideration. The estimate only took 3 major disease related to smoke, but didnt include digestive ulceration disease and liver cirrhosis, etc. It adopted NHSS data to estimate smoking rate. The smoking rate of male aged 15 years old and above was 48.0%, which was 4.9% lower than the data issued by Global Adult Tobacco Survey-China Region Results Presentation (52.9%). If latter smoking rate was adopted, economic burden attributable to smoking would increase sharply.

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.Discussion (4)4. Estimated RR related to smoking was far below one of western countries5. Effective demands of health service shifted. The lost supposed hospitalization rate was 21.0% and lost consultation rate was 32.8%. The economic burden attributable to smoking of those lost population can not be obtained. 6. The economic burden caused by absence on leave, suspension of schooling brought by taking care of patients were not taken into consideration. 7. Lacking of relevant data, economic burden brought by disability caused by diseases related to smoking were not taken into consideration.

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Acknowledgements Fogarty International Center (N01-TW05938 ), National Institute of Health (NIH)China Medical Board (CMB)Health Statistic Information Center, Ministry of HealthYANG Lian, HU The-wei, RAO Keqin, SONG Haiyan and FAN Shaoyu all are investigators of the research

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