Open Access Research BMJ Open: first published as 10.1136/bmjopen-2014-005199 on 9 July 2014. Downloaded from The costs of smoking and secondhand smokeexposureinTaiwan:aprevalence- based annual cost approach Hai-Yen Sung,1 Li-Chuan Chang,2 Yu-Wen Wen,3 Yi-Wen Tsai2 To cite: Sung H-Y, ABSTRACT et al Strengths and limitations of this study Chang L-C, Wen Y-W, . Objectives: To assess the costs of the health effects The costs of smoking and of cigarette smoking and secondhand smoke (SHS) ▪ secondhand smoke exposure Little is known about the economic costs of exposure to society. in Taiwan: a prevalence-based secondhand smoke (SHS) exposure in East Asian annual cost approach. BMJ Design: Prevalence-based, disease-specific cost-of- countries. This is the first study to assess the Open 2014;4:e005199. illness study. We used an epidemiological population- health effects of smoking by taking into account doi:10.1136/bmjopen-2014- attributable risk method to determine the costs that the economic impact of SHS exposure in Taiwan. 005199 can be attributed to smoking and SHS exposure. ▪ This study provides evidence on the economic Setting: Taiwan. effect of the recent reduction in smoking preva- ▸ Prepublication history for Participants: All adult population aged 35 and older. lence and SHS exposure on healthcare costs and this paper is available online. Primary outcome measures: Direct costs of productivity losses to Taiwanese society as a To view these files please healthcare expenditures spent for treating tobacco- result of implementing a comprehensive tobacco visit the journal online related diseases, indirect mortality costs measured by control programme in 2009. (http://dx.doi.org/10.1136/ the value of lost productivity due to tobacco-related ▪ Only adults aged 35 and older were included in bmjopen-2014-005199). premature deaths and indirect morbidity costs the study. ▪ The relative risks of healthcare cost for smokers Received 6 March 2014 measured by the value of time lost from work due to Revised 27 May 2014 tobacco-related illness. are assumed to be the same as the relative risks Accepted 18 June 2014 Results: In 2010, direct costs of smoking and SHS of death for smokers because of data limitation. exposure amounted to US$828 million, accounting for 3.4% of Taiwan’s total personal healthcare expenditures. Smoking and SHS exposure also the FCTC recommended tobacco control http://bmjopen.bmj.com/ ’ contributed to 15 555 premature deaths— programmes according to WHO sMPOWER corresponding to a loss of 284 765 years of life and (Monitoring, Protect, Offer, Warn, US$820 million in productivity—and US$22 million in Enforcement and Raise) criteria.3 As of 2010, indirect morbidity costs. These direct and indirect costs 37−53% of adult men in East Asia were totalled US$1670 million, representing 0.4% of current smokers and more than 46% of men Taiwan’s gross domestic product and averaging about were exposed to passive smoking at work- US$720/adult smoker. The share of the total costs was places.2 To enhance the incentives to imple- greater from active smoking (92%) than SHS exposure ment the promises of the ratified FCTC to on October 6, 2021 by guest. Protected copyright. (8%), and greater for men (92%) than women (8%). reduce the tobacco epidemic in East Asia, Conclusions: Smoking and SHS exposure impose a updating of evidence on the economic costs huge financial loss in Taiwan. Sustained tobacco control efforts to encourage people to quit smoking, due to active and passive smoking-caused prevent smoking uptake by children and young adults illness, disability and premature mortality in and protect all people from SHS exposure are needed. this region is imperative. Taiwan is regarded as a model in East Asia in tobacco control.2 During the 1960s and 1970s, smoking prevalence among Taiwanese aged 35 and above exceeded 75% for men and 8–12% INTRODUCTION for women.4 In 1987, Taiwan’scigarette East Asia is the world’s largest tobacco epi- market was forced to open to foreign brands, demic region, responsible for nearly half of leading to a 6% jump in adult male smoking total global cigarette consumption.1 Although and a 13% jump in youth smoking within For numbered affiliations see fi 4 end of article. all East Asian countries rati ed the WHO 3years. As a consequence, the government Framework Convention on Tobacco Control launched a series of tobacco control initiatives Correspondence to (FCTC) in 2004 or 2005, a recent assessment such as school-based antismoking programmes 2 Dr Hai-Yen Sung; study revealed that the majority of countries and the 1997 Tobacco Hazards Prevention Act [email protected] in East Asia lagged behind in implementing through which indoor workplaces and public Sung H-Y, et al. BMJ Open 2014;4:e005199. doi:10.1136/bmjopen-2014-005199 1 Open Access BMJ Open: first published as 10.1136/bmjopen-2014-005199 on 9 July 2014. Downloaded from places became partially smoke free.5 In 2002, the govern- tobacco-related diseases; indirect mortality costs mea- ment levied a tobacco tax amounting to five New Taiwan sured by the value of lost productivity due to premature Dollars (NT$) per pack and started the Outpatient death and indirect morbidity costs measured by the Smoking Cessation Services.5 During the period of 1990– value of time lost from work due to tobacco-related 2005, smoking prevalence among men aged 18 and older illness. A prevalence-based, disease-specific cost-of-illness had declined from 59.4% to 40%.5 Taiwan’s legislature rati- approach10 was used to estimate the healthcare expendi- fied the WHO FCTC in 2005. Based on the FCTC recom- tures, workloss days and deaths due to smoking-related mendations,6 an amendment to the Tobacco Hazards diseases in 2010. We used an epidemiological Prevention Act went into effect in 2009 (hereafter called population-attributable risk method11 to determine the the 2009 Act) to strengthen existing tobacco control mea- smoking-attributable fraction (SAF), which measures the sures by adding graphic warning labels on cigarette proportion of expenditures, workloss days or deaths that packets, extending smoke-free areas to almost all enclosed can be attributed to smoking, and applied it to the total workplaces and public places, completely banning tobacco measure. A SHS-attributable fraction (SAFSHS) was esti- advertisements, promotion and sponsorship, as well as mated in a similar manner. Our analyses focused on increasing tobacco taxes. adults aged 35 years and older. As a result of the 2009 Act, smoking prevalence among men aged 18 and older in Taiwan further decreased from Data sources 40% to 33.5% and exposure to passive smoking in work- Population-based data from the annual Adult Smoking places decreased substantially from 33.2% to 18.2% Behavior Survey (ASBS) were used to determine the between 2005 and 2011.57Given this sizeable reduction prevalence of smoking and SHS exposure. The ASBS is a in active and passive smoking, it is policy relevant to telephone interview survey collecting information on assess the current level of the costs of active and passive individuals’ demographic characteristics, cigarette smoking-attributable illness, disability and premature smoking and quitting behaviours, and SHS exposure mortality, and to determine whether or not these costs from a nationally representative sample (around 16 000/ have decreased. year) of a non-institutionalised population aged 18 and Two previous studies estimated the cost of smoking in older in Taiwan. Disease-specific inpatient and outpatient Taiwan. Using a prevalence-based approach, Yang et al8 expenditures, and number of hospital inpatient days were estimated that in 2001, smoking contributed to US$398 obtained from the 2010 National Health Insurance million in excess medical expenditures and US$1390 (NHI) claims database. Taiwan’s NHI, launched in 1995, million in productivity loss from premature death is a mandatory single-payer social health insurance system among people aged 35 and older in Taiwan. Using an administered by the government that provides universal 9 incidence-based approach, Chung et al estimated that healthcare coverage to virtually all citizens in Taiwan. http://bmjopen.bmj.com/ the present value of lifetime smoking-attributable Population data came from the 2010 Population medical costs among people aged 35 and older ranged Census,12 number of deaths for each disease from the from US$291 to US$336 million depending on discount 2010 Statistics of Causes of Death13 and life expectancy rate for the year 2001 in Taiwan. There has been no by age and gender from the 2010 life tables.14 The age- study to update these cost estimates in Taiwan since specific and gender-specific employment rates and 2001. Furthermore, none of the studies on the cost of monthly earnings were obtained from the 2010 Report smoking in Taiwan and few of those in the literature on the Manpower Utilization Survey.15 have included any health costs attributed to passive on October 6, 2021 by guest. Protected copyright. smoking, also known as secondhand smoke (SHS). Smoking-related and SHS-associated diseases The main objective of this study is to assess the costs We included 19 smoking-related diseases which were of the health effects of cigarette smoking and SHS identified to have a significant association between cigar- exposure in Taiwan in 2010. This is the first attempt to ette smoking and mortality risk by two large epidemio- quantify the economic costs of SHS exposure in Taiwan. logical studies conducted in Taiwan.16 17 We considered This study will also provide an evaluation on the hypoth- six SHS-associated diseases: lung cancer, ischaemic heart esis that implementation of the 2009 Act was associated disease, cerebrovascular disease, chronic obstructive pul- with decreases in economic costs of smoking and SHS monary disease, asthma and breast cancer; and four exposure.