TOBACCOCONTROL42028 266..272

Objective To estimate the health-related economic costs attributable to smoking in China for persons aged 35 and older in 2003 and in 2008 and to compare these costs with the respective results from 2000. Methods A prevalence-based, disease-specific approach was used to estimate smoking-attributable direct and indirect economic costs. The primary data source was the 2003 and 2008 China National Health Services Survey, which contains individual participant’s smoking status, healthcare use and expenditures. Results The total economic cost of smoking in China amounted to $17.1 billion in 2003 and $28.9 billion in 2008 (both measured in 2008 constant US$). Direct smoking-attributable healthcare costs in 2003 and 2008 were $4.2 billion and $6.2 billion, respectively. Indirect economic costs in 2003 and 2008 were $12.9 billion and $22.7 billion, respectively. Compared to 2000, the direct costs of smoking rose by 72% in 2003 and 154% in 2008, while the indirect costs of smoking rose by 170% in 2003 and 376% in 2008. Conclusions The economic burden of cigarette smoking has increased substantially in China during the past decade and is expected to continue to increase as the national economy and the price of healthcare services grow. Stronger intervention measures against smoking should be taken without delay to reduce the health and financial losses caused by smoking. INTRODUCTION With 301 million current smokers in 2010, China is the largest consumer of tobacco in the world. In 2010, 52.9% of Chinese men and 2.4% of women were current smokers. Despite numerous studies demonstrating that tobacco is harmful for health and evidence showing that the overall mortality of smokers in China is significantly higher than that of never smokers, most Chinese citizens still lack understanding of the harmful effects of smoking. In 2010, only 23.2% of Chinese adults believed smoking causes stroke, heart attack and lung cancer, and only 16.1% of current smokers planned to or were thinking about quitting in the next 12 months. At the same time, China is the world’s largest producer of tobacco. All cigarettes are produced by the state-owned tobacco monopoly company, and about 7.0% of China’s central government revenue was generated from tobacco profit and taxes. Because of the economic interests of the tobacco industry, Chinese policymakers are unwilling to restrict promotion of tobacco products and to implement stricter legislation to protect nonsmokers. To raise the general Chinese population’s awareness of the dangers of smoking and to increase the government’s incentive to implement the promises of the ratified WHO’s Framework Convention on Tobacco Control, it is important to transform the data on the health effects of smoking into monetary values of financial losses to the society. There is a paucity of national studies estimating the economic costs of smoking in China. Using a medical cost accounting method to calculate disease-specific medical costs, Chen et al estimated the total medical costs attributable to smoking in 1988 in China at U2.3 billion (US$0.28 billion using the exchange rate of U8.2784 to US$1). Jin et al estimated the total economic burden of smoking in China in 1989 at U27.1 billion ($3.27 billion using the exchange rate of U8.2784 to US$1), including U6.9 billion ($0.83 billion) of direct medical costs and U20.1 billion ($2.43 billion) of indirect morbidity and mortality costs. Sung et al estimated the economic costs of smoking in China in 2000 at $5.0 billion (based on the exchange rate of U8.2784 to US$1), of which $1.7 billion were direct healthcare costs of smoking and $3.3 billion were indirect morbidity and mortality costs. These three studies of the costs of smoking in China were conducted more than 10 years ago. Due to China’s economic growth and the introduction of high-tech medical equipment, wage rates and healthcare expenditures in China have increased substantially during the last decade. Therefore, the economic burden of smoking in China is very likely to have increased dramatically as well. It is important to examine the trend of smoking-attributable costs during the last decade. The objective of this paper was to provide the latest estimates for direct and indirect costs of smoking in China by using data from the third and fourth waves of the China National Health Services Survey (NHSS) conducted in 2003 and 2008 and to compare these cost estimates with the respective 2000 estimates from the previous study by Sung et al. METHODS We divided the economic costs of smoking into two components: direct costs and indirect costs. Direct costs include all healthcare expenditures for treating smoking-related diseases. Indirect costs include expenses for transportation, nutritious supplemental food and caregivers during inpatient hospitalisations and outpatient visits due to treating smoking-related diseases, the value of lost productivity caused by smoking-related illness, and indirect mortality costs of premature deaths caused by smoking-related diseases. Healthcare services comprise outpatient visits, inpatient Department of Health Economics, Huaxi School of Public Health, University of Sichuan, Chengdu, China Department of Health Economics, School of Public Health and Administration, Chengdu University of Traditional Chinese Medicine, Chengdu, China Institute for Health & Ageing, University of California, San Francisco, California, USA School of Public Health, University of California, Berkeley, California, USA Centre of Health Statistics and Information, Ministry of Health,