2015-5-211 Economic Burden Attributable to Smoking in China A
new estimate based on national-wide data Sichuan University
Zhengzhong Mao Lijiang Yunnan 2011.10
Slide 2
Contents I.Background II.Estimation Method III.Estimated Result
IV.Discussion
Slide 3
I. Background 1 There 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 2015-5-213
Slide 4
I.Background 2 Literature Review of Economic Burden
Attributable to Smoking in China AuthorYearCost Chen et al1988 2.3
billion RMB (280 million US dollars ( only medical costs
attributable to smoking ) Jin et al1989 27.1 billion RMB 3. 3
billion US dollars (total economic burden attributable to smoking )
Sung et al2000 41 billion RMB 5 billion US dollars (total economic
attributable to smoking ) LI et al2005 252.67 286.06 billion RMB 36
41 billion US dollars 2015-5-214 ( total economic attributable to
smoking )
Slide 5
.Estimation Method 2015-5-215 Smoking Attributable Fraction
(SAF) 3 Indirect Disease Cost 5 Indirect mortality costs 61 Direct
Medical Cost 4 2 Data Sources Related Population and Diseases
Slide 6
1. Data Sources The data of smoking rate, inpatient and
outpatient service cost, and absence on leave, etc were derived
from the family health questionnaire of 3 rd (in 2003) and 4 th (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) Remarks No
differentiation between previous smoker and current smoker during
calculation, that is, the smoking status only is divided into
smoker and non-smoker. 2015-5-216
Slide 7
2.Related Population and Diseases Population: aged 35+ Three
categories of smoking-related diseases Cancer (ICD10 C00C97)
Cardiovascular Diseases (ICD10 I00I99) Respiratory Diseases (ICD10
J00J99) 2015-5-217
Slide 8
8 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 ; R rural or urban; S : gender; A : age group: 35~64, or
65+. (1) SAF estimates the proportion of medical service
attributable to smoking.
Slide 9
2015-5-219 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).
Slide 10
2015-5-2110 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 visit IDAY: 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)
Slide 11
2015-5-2111 6. Indirect mortality costs SADirsa= [DRATEirsa
POPrsa] SAFirsa SAYPLLirsa= SADirsa LErsa PVLErsa = SAMCirsa=
SADirsa PVLErsa DRATE : mortality per 100,000 persons LE: average
number of years of life expectancy remaining at the age of death
SURV(m): probability that a person will survive to age m maxa : the
oldest age group (e.g., age 85+) Y(m) : mean annual earnings of an
employed person at age m E(m) : proportion of the population of age
m that is employed in the labor market g : growth rate of labor
productivity V : discount rate a: age at death Subscription has
same meaning with formula (1)
Slide 12
.Estimated Result 2015-5-2112 5. Comparison Among 3 Study
Results 4. Economic Burden Attributable to Smoking 3. Years of
Potential life lost 2. Smoking-attributable Fraction (SAF) 1.
smoking prevalence rate
Slide 13
20032008 Total33.131.4 Female in Rural Area4.64.5 35~644.03.9
65+7.87.2 Female in City5.34.7 35~643.53.7 65+10.77.4 Male in Rural
Area6461.3 35~6465.262.9 65+58.054.0 Male in City56.153.0
35~6460.358.1 65+42.337.1 2015-5-2113 Table 1. Smoking Rate of
Adult aged 35 years old and above in China(%) (National Health
Service Survey Data)
Slide 14
2015-5-2114 2. Smoking-Attributable Fraction (SAF) RR* SAF (%)
UrbanRural MaleFemaleMaleFemaleMaleFemale
35~6465+35~6465+35~6465+35~6465+ Respiratory diseases
1.11.437.524.931.573.088.097.031.653.00 Cardiovascular diseases
1.21.218.995.930.771.539.668.410.811.49 Cancer1.61.62
24.2216.952.244.3925.722.92.364.27 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)
Slide 15
2015-5-2115 3. Years of potential life lost DeathsYPLLs Male
495,0537,785,011 Female 57,227720,609 35~64 215,9945,340,087 65+
336,2863,165,533 Urban 154,7452,396,498 Rural 397,5356,109,122
Respiratory diseases 61,514628,559 Cardiovascular
diseases147,7921,882,707 Cancer342,9745,994,354 Total
552,2808,505,620 Table 3. Number of deaths and years of potential
life lost (YPLLs ) attributable to smoking in China, 2008, among
adults aged 35 and older
Slide 16
2015-5-2116 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)
Slide 17
2015-5-2117 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.
Slide 18
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%. Items Amount RMB ) 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%
($1.00= RMB6.80)
Slide 19
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 (1 st, 2004) ItemAmount Lung Cancer
Patient 10 thousand 68.6 Smoker Proportion among Lung Cancer
Patient64.08% Smokers among Lung Cancer Patient 10 thousand 43.96
Cost of treating Lung Cancer (Yuan/ Case)118770.56 Predicted total
Economic Burden of Lung Cancer attributable to smoking (100 million
Yuan) 522.12 Almost Equivalent to7.67 8 billion US dollars
Slide 20
.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%. 2015-5-2120
Slide 21
.Discussion (2) Changes brought by economic burden attributable
to smoking in past 8 years 2015-5-2121 + 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.
Slide 22
.Discussion (3) The estimates for the costs of smoking may be
under-estimated for several reasons 1.Economic burden brought by
passive smoking wasnt taken into consideration. 2.The estimate only
took 3 major disease related to smoke, but didnt include digestive
ulceration disease and liver cirrhosis, etc. 3.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. 2015-5-2122
Slide 23
.Discussion (4) 4. Estimated RR related to smoking was far
below one of western countries 5. 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. 2015-5-2123
Slide 24
Acknowledgements Fogarty International Center (N01-TW05938 ),
National Institute of Health (NIH) China Medical Board (CMB) Health
Statistic Information Center, Ministry of Health YANG Lian, HU
The-wei, RAO Keqin, SONG Haiyan and FAN Shaoyu all are
investigators of the research 2015-5-2124