Dorothy P Rice, Institute for Health & Aging, University of California, 3333 California St., Suite 340, San Francisco, CA 94118, USA. E-mail: rice{at}itsa.ucsf.edu
The article by Yoko et al.1 in this issue of the International Journal of Epidemiology estimates the excess medical care costs of smokers aged 45 years in Japan. The authors found that more than half (54.9%) of the men were current smokers and per capita medical costs for males was 11% higher than for never smokers. They conclude that 3.8% of total medical costs was attributable to smoking. The authors recognize that this proportion is low compared with that for the US, where the prevalence of smoking among adults is 26%, much lower than for males in Japan. The authors cite 7.1% of medical care costs was estimated to be attributable to smoking in the US. A later study2 reported 11.8% of medical expenditures for people
19 years was attributable to smoking in the US. The authors wisely point out that although their estimates for Japan seem to be relatively small, the differences in the estimation methods and definition of medical care costs should be considered when making such comparisons between Japan and the US.
It is important to note that this study by Yoko et al. is limited to estimates of the direct medical care costs attributable to smoking, thereby understating the total burden of smoking in Japan. In addition to the direct medical costs, the indirect costs of smoking should be added. These indirect costs of smoking include the value of lost productivity, output or forgone resources when people lose time from work and other productive activities due to morbidity, disability, or premature death caused by smoking-induced illnesses. One study in the US3 reported that indirect costs of smoking amounted to more than the direct costs.
These findings on the excess use of medical care services and the cost of smoking in Japan should be seen in the larger context of the global smoking epidemic. This devastating epidemic places an enormous burden on societies, including excess use of medical care services, loss of productivity for people unable to work or perform their usual activities, and premature deaths attributable to smoking.
There are currently 1.1 billion smokers in the world; by 2025, the number is expected to rise to more than 1.6 billion.4 In the high-income countries, smoking rates have been in overall decline, although they continue to rise in some groups. By contrast, in low- and middle-income countries cigarette consumption has been increasing. Freer trade in cigarettes, and increased advertising and marketing have contributed to the rising consumption in low-income countries in recent years.
Smoking causes disabling and fatal diseases, and compared with other risky behaviours, the risk of premature death is extremely high. Half of all long-term smokers will eventually be killed by tobacco, and of these, half will die during productive middle age, losing 20 to 25 years of productive life.4 In addition to the health risks of smoking, there are important economic consequences. Quantifying the medical expenditures attributed to smoking as well as the value of productivity lost to morbidity, disability, and premature mortality among smokers in developed as well as less-developed countries is essential. It translates the burden of medical care and productivity losses associated with smoking into dollar terms, the universal language of decision makers. A common metric for combining morbidity and mortality is to use monetary terms. Such estimates can be used by various countries to define the impact of cigarette smoking on the delivery and financing of medical care services, to justify economic interventions such as increases in cigarette taxes, to guide government health policy and planning relative to smoking control initiatives, and to provide an economic framework for programme evaluation. In the US, such estimates have been used in litigation against the tobacco industry to recover smoking-related medical care expenditures.
The article by Yoko et al. on the medical care use and costs of smoking in Japan contributes to the growing literature on the costs of smoking in countries throughout the world. Illustrative of recent cost of smoking studies include those for Australia,5 Canada,6 China,7 Finland,8 The Netherlands,9 Switzerland,10 and the US.11 Obviously, fewer studies of the costs of smoking in less-developed countries have been undertaken. Although there are differences in methods and results from one country to another, it is important to emphasize that smoking is responsible for a significant portion of each nation's medical care expenditures and imposes a considerable financial burden. In less-developed countries, that share is likely to grow in the future as these countries experience longer histories of tobacco use and as smokers increase their cigarette use with increasing affluence. There is a need to develop the necessary databases by both developed and less-developed countries to monitor the economic costs of smoking in their respective countries.
Each country will wish to reduce their quantifiable financial costs as well as the unquantifiable suffering caused by tobacco's burden of disease and premature death in the future. A multi-pronged strategy should be adopted to deter children from smoking, to protect non-smokers, and to encourage current smokers to quit. Strategies tailored to the needs of individual countries include: raising taxes, publishing and disseminating research results on the health effects of smoking, adding prominent warning labels to cigarettes, adopting comprehensive bans on advertising and promotions, restricting smoking in workplaces, and widening access to nicotine replacement and other cessation therapies.4 The threat of the devastating effects of smoking to global health is unprecedented, but so is the potential for reducing smoking-related morbidity, mortality, and costs.
References
1
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8 Pekurinen M. Economic consequences of smoking in Finland. In: Jeanrenaud C, Soguel N (eds). Valuing the Cost of Smoking: Assessment Methods, Risk Perception, and Policy Options. Boston/Dordrecht/London: Kluwer Academic Publishers, 1999, pp.11126.
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11 Rice DP. Measurement of the economic costs of smoking in the United States: an historical review. In: Jeanrenaud C, Soguel N (eds). Valuing the Cost of Smoking: Assessment Methods, Risk Perception, and Policy Options. Boston/Dordrecht/London: Kluwer Academic Publishers, 1999, pp.1129.