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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

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Contents I.Background II.Estimation Method III.Estimated Result IV.Discussion

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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

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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 )

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.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

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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

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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

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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.

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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).

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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)

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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)

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.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

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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)

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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)

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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

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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)

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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.

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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)

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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

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.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

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.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.

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.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

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.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

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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 Health YANG Lian, HU The-wei, RAO Keqin, SONG Haiyan and FAN Shaoyu all are investigators of the research 2015-5-2124

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Thank you Please make comments and suggestions