Economic Burden
Attributable to Smoking in China
——A new estimate based on national-wide data
Sichuan University
Zhengzhong Mao
Lijiang Yunnan 2011.10
2015/4/13
1
Contents
I.
II.
III.
IV.
Background
Estimation Method
Estimated Result
Discussion
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
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I.
•
Background（2）
Literature Review of Economic Burden Attributable to Smoking in China
Author
Year
Chen et al
1988
Jin et al
1989
Sung et al
2000
LI et al
2005
Cost
2.3 billion RMB (280 million US dollars）
( only medical costs attributable to smoking)
27.1 billion RMB（3. 3 billion US dollars）
(total economic burden attributable to smoking )
41 billion RMB （5 billion US dollars）
(total economic attributable to smoking )
252.67～286.06 billion RMB（36～41 billion
US dollars）
(total economic attributable to smoking )
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Ⅱ.Estimation Method
1
Data Sources
2
Related Population and Diseases
3
2015/4/13
Smoking Attributable Fraction (SAF)
4
Direct Medical Cost
5
Indirect Disease Cost
6
Indirect mortality costs
5
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 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)
Remarks：No differentiation between previous smoker and current smoker during
calculation, that is, the smoking status only is divided into smoker and non-smoker.
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2.Related Population and Diseases
• Population: aged 35+
• Three categories of smoking-related diseases
Cancer (ICD–10：C00–C97)
Cardiovascular Diseases (ICD–10：I00–I99)
Respiratory Diseases (ICD–10：J00–J99)
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3. Smoking-attributable Fraction
(SAF)
SAF estimates the proportion of medical service attributable to smoking.

PNrsa  PSrsa  RRirsa   1
SAFirsa 
PNrsa  PSrsa  RRirsa 
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+.
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(1)
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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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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6. Indirect mortality costs
• SADirsa= [DRATEirsa× POPrsa] × SAFirsa
• SAYPLLirsa= SADirsa× LErsa
max a
• PVLErsa = [SURVrsa (m)][Yr (m)  Ers (m)]  (1  g ) ma /(1  V ) ma
m a
• 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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Ⅲ.Estimated Result
1. smoking prevalence rate
2. Smoking-attributable Fraction (SAF)
3. Years of Potential life lost
4. Economic Burden Attributable to Smoking
5. Comparison Among 3 Study Results
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1. smoking prevalence rate
Table 1. Smoking Rate of Adult aged 35 years old and above in China(%)
(National Health Service Survey Data)
2003
2008
Total
33.1
31.4
Female in Rural Area
4.6
4.5
35~64
4.0
3.9
65+
7.8
7.2
5.3
4.7
35~64
3.5
3.7
65+
10.7
7.4
64
61.3
35~64
65.2
62.9
65+
58.0
54.0
56.1
53.0
35~64
60.3
58.1
65+
42.3
37.1
Female in City
Male in Rural Area
Male in City
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2. Smoking-Attributable Fraction
(SAF)
Table 2. Disease-specific relative risk of mortality for smokers and smokingattributable fractions (SAFs) in China, 2008, age for adults aged 35 and older
RR*
SAF (%)
Urban
Male
Female
Male
Rural
Female
Male
Female
35~64
65+
35~64
65+
35~64
65+
35~64
65+
Respiratory
diseases
1.1
1.43
7.52
4.93
1.57
3.08
8.09
7.03
1.65
3.00
Cardiovascular
diseases
1.2
1.21
8.99
5.93
0.77
1.53
9.66
8.41
0.81
1.49
Cancer
1.6
1.62
24.22
16.95
2.24
4.39
25.7
22.9
2.36
4.27
* Source: Gu and Kelly et al. (2009)
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3. Years of potential life lost
Table 3. Number of deaths and years of potential life lost (YPLLs )
attributable to smoking in China, 2008, among adults aged 35 and older
2015/4/13
Deaths
YPLLs
Male
495,053
7,785,011
Female
57,227
720,609
35~64
215,994
5,340,087
65+
336,286
3,165,533
Urban
154,745
2,396,498
Rural
397,535
6,109,122
Respiratory diseases
61,514
628,559
Cardiovascular diseases
147,792
1,882,707
Cancer
342,974
5,994,354
Total
552,280
8,505,620
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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)
Direct medical cost
Outpatient
Male
Female
35~64
65+
Urban
Rural
Respiratory
diseases
Cardiovascular
diseases
Cancer
Total
2015/4/13
Inpatient
Subtotal
Indirect cost
indirect morbidity cost
Indirect
transporta
Absence
mortality costs
tion and
from work
caregivers
Subtotal
Total
40.5
4.9
24.5
20.9
20.0
25.4
14.8
1.8
9.9
6.8
8.4
8.3
55.4
6.6
34.4
27.6
28.4
33.7
3.3
0.5
2.5
1.3
1.4
2.5
2.3
0.4
2.2
0.4
0.7
1.9
207.8
12.3
202.0
18.0
104.7
115.3
213.4
13.1
206.7
19.8
106.8
119.7
268.7
19.8
241.1
47.4
135.1
153.4
7.6
1.7
9.3
0.8
1.1
8.3
10.2
19.6
21.8
7.3
29.1
1.7
1.1
40.1
42.9
72.0
16.0
45.4
7.6
16.6
23.6
62.0
1.4
3.8
0.4
2.6
171.6
220.0
173.4
226.5
197.0
288.5
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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)
2000
Mortality
YPLL
Direct costs
Outpatient visits
Inpatient
hospitalization
Self-medication
Indirect costs
Transportation
and caregivers
Absence from
work
Mortality
Total
2015/4/13
2003
2008
Percentage
Change(%)
Percentage
Change (%)
2000 - 2003
2000 - 2008
688,512
9,699,251
574,107
8,162,771
552,280
8,505,620
-16.62
-15.84
-19.79
-12.31
24.4
12.9
42.0
24.7
62.0
45.4
72.07
92.31
154.19
253.04
9.4
6.5
16.6
-30.36
77.56
2.2
47.6
10.7
128.7
—
226.5
392.57
170.34
—
375.75
1.8
1.5
3.8
-14.74
118.81
3.9
1.6
2.6
-58.81
-32.24
42.0
72.0
125.6
170.1
220.0
288.5
199.19
137.04
424.07
300.68
* 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)
Items
Amount（RMB )
Ratio
Direct Medical Cost
67430.01
56.77%
Indirect Medical Cost
2596.23
2.19%
Direct Economic Burden
70026.24
58.96%
Indirect Economic Burden
48744.32
41.04%
118770.56 ($17466.3)
100%
Total Economic Burden
($1.00= RMB6.80)
•
Sample size= 650 patients with lung cancer ; available sample: 618 in which there were 396
smokers. The proportion of smoker was 64.08%.
Total Lung Cancer Economic Burden
attributable to Smoking
•
•
Item
Amount
Lung Cancer Patient（10 thousand）
68.6
Smoker Proportion among Lung Cancer Patient
64.08%
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 to
7.67 8 billion US dollars
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)
Ⅳ.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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Ⅳ.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.
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Ⅳ.Discussion (3)
• The estimates for the costs of smoking may be
under-estimated for several reasons
1. Economic burden brought by passive smoking wasn’t taken into
consideration.
2. The estimate only took 3 major disease related to smoke, but
didn’t 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.
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Ⅳ.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.
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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
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Thank you！
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