The results of this study indicate that the adverse health effects of smoking cause a huge economic burden to the Chinese society, reaching $5034.2 million in 2000. Results also show that $1705.7 million, 3.1% of the national health care expenditures, were spent on treating smoking‐related diseases.
Compared to Western countries such as the USA where smoking attributable direct costs accounted for 6–8% of national personal health care expenditures,9
our estimates seem low. Our estimates are likely conservative for several reasons.
First, we used the RRs from a retrospective mortality study of one million deaths by Liu et al13
and their estimates were much lower than those from Western countries. For example, the RRs of lung cancer among men aged 35 and older were 2.98 for urban smokers and 2.57 for rural smokers in China compared to 22.36 for current smokers and 9.36 for former smokers in the USA.22
The RRs of coronary heart disease among men aged 35–64 were 1.28 for both urban and rural smokers in China versus 2.81 for current smokers and 1.75 for former smokers in the USA.22
Few studies have assessed the RRs of smoking for the Chinese population.13,23,24,25,26
We chose the estimates by Liu et al13
because their study was based on a large national sample and was the only study providing the RR estimates by gender and rural/urban district. In general, the RRs estimated by Liu et al
were comparable to those from other Chinese prospective studies and case–control studies.13
However, Lam et al26
have argued that most studies on smoking‐related mortality in China tend to underestimate the RRs of smoking because of the short follow‐up. They demonstrated that as the duration of follow‐up period increased, RRs also increased. Based on 20 years of follow‐up, their estimated RRs were similar to those in the USA and the UK. We conducted a sensitivity analysis by using the RRs estimated by Lam et al26
while keeping other data unchanged. The total economic costs of smoking more than doubled, from $5034 million to $12
151 million, and the proportion of smoking attributable direct costs to the national health expenditures increased to 7.7%, comparable to that in the USA.
Second, when estimating PVLE, we assumed earnings were the same for all subgroups by age and gender because of the data limitation. As shown in the Appendix, the PVLE is the highest for persons < 1 year and decreases with age. Max et al20
found that the American males and females aged 20–24 have the highest PVLE at a discount rate of 3% given the varying earnings for each five‐year age group. If the pattern of earnings by age in China is similar to that in the USA, our PVLE estimates may be overestimated for persons younger than age 20 and underestimated for persons
20; therefore, our estimated indirect costs of smoking for persons aged 35 and older may be underestimated. Also, we assumed 8% as the annual growth rate in productivity that is lower than the average growth rate of GDP in China during 1979–2002 at 9.4%.17
According to China's National Bureau of Statistics, the annual rates of GDP growth in 2003 and 2004 reached 10%. The estimated costs of smoking would be higher if the growth rate of 9.4% is assumed. However, if we assume the growth rate in China will be reduced to 5% beginning in 2006, the indirect mortality costs of smoking would be reduced from $2.9 billion to $2.2 billion.
Third, we estimated the smoking prevalence rates by using the 1998 NHSS data. Yang et al27
estimated that the prevalence rate of ever‐smokers for persons aged 15–69 was 66.9% for men and 4.2% for women using the 1996 National Prevalence Survey. Applying the same age criteria, the corresponding rate was 57.5% for men and 3.8% for women from the 1998 NHSS data. In other words, our estimate was about 15% lower for men and 10% lower for women than the estimates by Yang et al
. This could be due to an underreporting of smoking status among respondents in the 1998 NHSS. We conducted another sensitivity analysis by increasing the smoking prevalence rate by 15% for each age group for men while keeping other things unchanged. The total economic costs of smoking increased by about 10%, from $5034 million to $5569 million.
Fourth, our calculation for the economic burden of smoking only considers the three major categories of smoking‐related diseases. We did not include peptic ulcer diseases and liver cirrhosis, two diseases estimated to account for 14–19% of smoking attributable medical costs, YPLLs, and mortality costs according to two recent studies in Asia.28,29
Additionally, Yang et al29
found that kidney diseases caused the most smoking attributable medical costs. Further research is needed to examine the effects of smoking on the morbidity and mortality resulting from peptic ulcer, liver cirrhosis, and kidney diseases and their economic costs among the Chinese population.
Finally, we did not count the days lost from work by the relatives taking care of patients with smoking‐related illness, the health care costs of environmental tobacco smoke, and the deaths resulting from cigarette‐caused fires and passive smoking. For persons younger than age 35, passive smoking is the main risk for diseases such as bronchitis and low birth weight. Yang et al1
estimated that more than 50% of Chinese non‐smokers aged 15 and older were passive smokers in 2002. Therefore, the true economic burden of smoking in China could be much higher than the estimates in this study, which only focuses on the evaluation of active smoking.
This study is based on the conventional epidemiological approach6,7,29
which estimates the smoking attributable risks of mortality caused by the three major smoking‐related diseases, and applies the attributable risks of mortality to the morbidity toll. In an alternative epidemiological approach,8,28
the smoking attributable risks of healthcare utilisation for smoking‐related diseases are estimated and applied to healthcare expenditures. Several recent studies in the USA have developed the econometric approach10,30,31,32
which examines the relationship between smoking and healthcare expenditures in a multi‐equation framework by adjusting other risk factors, health status, and individuals' taste for consuming health care. These econometric studies estimate smokers' total excess expenditures over those of non‐smokers by including all types of diseases. Warner et al9
anticipate that the econometric approach will become the norm in cost‐of‐smoking analyses. Due to the limitation of our data, neither the smoking attributable risks of healthcare utilisation nor the econometric models are estimated in this study.
In conclusion, our very conservatively estimated results suggest that cigarette smoking costs an enormous economic burden in China through a huge number of preventable diseases, health care costs, premature deaths, and productivity losses. The total economic costs had grown from $3.3 billion in 19895
to $5.0 billion in 2000. Since the health effects of smoking on morbidity and mortality are cumulative, China will bear a much heavier economic burden from cigarette smoking in the future if the current trends in smoking behaviour continue. The economic burden of smoking in the rural areas will be of special concern because of the large proportion of population, the high smoking prevalence rate, and poverty. To reduce the economic burden of smoking to the society, effective tobacco control programmes and sustained efforts are needed in China to curb the tobacco epidemic. We hope that the results of this study will motivate policymakers in China to formulate a comprehensive health and economic agenda with adequate investment in research, public education, health providers' training, and intervention programmes aimed at tobacco prevention and control.
What this paper adds
This paper provides an updated and comprehensive estimate of the economic costs of smoking in China. Our findings justify the need for stronger tobacco control policies in China.