Smoking, healthcare cost, and loss of productivity in Sweden 2001

Author(s): KRISTIAN BOLIN and BJÖRN LINDGREN

Source: Scandinavian Journal of Public Health , 2007, Vol. 35, No. 2 (2007), pp. 187-196
Published by: Sage Publications, Ltd.

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Scandinavian Journal of Public Healthy 2007; 35: 187-196 informa healthcare

ORIGINAL ARTICLE

Smoking, healthcare cost, and loss of productivity in Sweden 2001

KRISTIÁN BOLIN & BJÖRN LINDGREN

Department of Health Sciences , Lund University, Lund University Centre for Health Economics (LUCHE), and the Vàrdal
Institute, Sweden

Abstract
Aims: Objectives were (a) to estimate healthcare cost and productivity losses due to smoking in Sweden 2001 and (b) to
compare the results with studies for Sweden 1980, Canada 1991, Germany 1996, and the USA 1998. Methods: Published
estimates on relative risks and Swedish smoking patterns were used to calculate attributable risks for smokers and former
smokers. These were applied to cost estimates for smoking-related diseases based on data from public Swedish registers.
Results: The estimated total cost for Sweden 2001 was USft 804 million; COPD and cancer of the lung accounted for 43%.
Healthcare cost accounted for 26% of the total cost. The estimated costs per smoker were US$ 3,200 in the USA 1998;
1,600 in Canada 1991; 1,100 in Germany 1996; 600 in Sweden 2001; and 300 in Sweden 1980 (all in 2001 US$ prices).
Conclusions: To reduce the prevalence of smoking is an issue worthwhile pursuing in its own right. In order to reduce the
cost of smoking, however, policy-makers should also explore and influence the factors that determine the cost per smoker.
Sweden seems to have been more successful than comparable countries in pursuing both these objectives.

Key Words: Canada, Germany, healthcare cost, loss of productivity, smoking, Sweden, USA

Introduction In the 2004 Surgeon General's report on diseases

Smoking damages your health and increases the
probability of disease. This is not just a label put on
your package of cigarettes but a fact that has been
known for quite some time [1-7]. The epidemiolo-
gical evidence has improved as the duration of
follow-up time has become longer, and the number
of diseases as well as the relative risks that are firmly
associated with smoking have increased. We now
know that the relative risks of dying from lung cancer
(and many other types of cancer), chronic obstruc-
tive pulmonary disease (COPD), coronary heart
disease, stroke, peripheral vascular disease, peptic
caused by smoking, for instance, the list of smoking-
attributable diseases now includes stomach cancer
and acute myeloid leukaemia but excludes hyperten-
sion [9]. Smoking during pregnancy can cause
spontaneous abortion, stillbirth, low birthweight,
and sudden infant death syndrome. It may also have
adverse effects on toddlers' behaviour, interfere with
cognitive performance, and increase the probability
that the child becomes a smoker later in life. For
non-smokers, passive exposure increases the risk of
lung cancer, heart disease, and respiratory illness
[10].

ulcer disease, and several other diseases are higher
among smokers than among never-smokers or
former smokers. The excess mortality of smokers is
substantially higher than previous estimates and
suggests that half of all regular smokers can expect
to die prematurely from tobacco use [8] . The
epidemiological evidence has not yet been finalized.
Despite this well-documented hazardous impact
of smoking on morbidity and life expectancy, the
number of people who smoke is enormous. It has
been estimated that some 47% of all men and 12%
of all women in the world smoke [8]. Among men,
the prevalence is currently highest (60-70%) in, for
instance, China, Japan, Latvia, and Turkey. Among

Correspondence: Björn Lindgren, LUCHE, PO Box 705, SE-220 07 Lund, Sweden. Tel: +46 46 222 0658. Fax: +46 46 222 0651. E-mail:
Bj orn.Lindgren@luche. lu. se

(Accepted 9 June 2006)

ISSN 1403-4948 print/ISSN 1651-1905 online/07/020187-10 © 2007 Taylor & Francis

DOI: 10.1080/14034940600858557

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188 K. Bolin & B. Lindgren
women, more than 35% smoke in Denmark and
Norway but less than 5% in India, Pakistan, or
Egypt. High prevalence rates and the health hazards
involved make tobacco use the single most important
preventable health risk in the developed world. In
developing countries, the prevalence of smoking is
increasing, and estimates tell us that, by the time the
young smokers of today reach middle age, smoking
will be causing some 10 million deaths per year
worldwide, 7 million of them in developing countries
[8],
Thus, there is a clear negative impact of smoking
on both individual and population health.
Economists attempt to put a monetary value on this
impact. Cost figures, however, can be used in a
variety of ways and for a variety of reasons. Some
studies consider projections into the future and
calculate whether a smoker will have higher or lower
healthcare cost than a non-smoker during his or her
lifetime [11-13]. Other studies try to figure out
whether the tax and welfare system is fair to smokers
or non-smokers [14-17]. Closely related to such
analyses are studies that attempt to estimate the
negative externalities of smoking, i.e. the costs that
are generated above the private benefits of the
smokers themselves [18,19]. Still other studies make
attempts to find out which smoking cessation
interventions are the most cost-effective [20-24] .
There are also studies such as the present one with
the more humble objective of estimating the total
costs in terms of healthcare and/or productivity
losses attributable to smoking in a single year [25-
32]. The objectives of all these types of studies are
perfectly respectable. However, a single study can
answer only one of them. If you want to know
whether smokers pay their bill, it is a different story
from that which tells you about the economic impact
of smoking on healthcare costs and the loss of
productivity in a specific year.
The impact of smoking on healthcare costs and
the loss of productivity in a single year has been
studied repeatedly in the USA, at least since the
1970s [33], while there are comparatively few
published studies available from other countries. In
the USA, there have also been a number of studies
for specific states; for California, for instance, there
have been at least nine studies since 1985 [34].
Studies from the 1970s and early 1980s all used the
"epidemiological approach", i.e. epidemiological
evidence of mortality attributed to smoking in order
to calculate both healthcare cost and lost productiv-
ity. Since then, most US studies have used a "mixed
approach", i.e. the impact on lost productivity
has been calculated following the "epidemiological
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approach", while the impact on healthcare cost has
been estimated using an "econometric approach".
The latter implies multiple-regression analyses on
personal healthcare expenditure data that include
information on factors besides smoking that may
affect healthcare expenditure, such as other risk
behaviours, socioeconomic status, and demographic
characteristics.
Healthcare cost and productivity losses due to
smoking have been estimated once before in
Sweden, for 1980 [27]. Several changes, which
might have had an effect on the estimated cost of
smoking, have occurred since 1980, for instance in
technologies, health insurance, epidemiological
knowledge, and, not least, in smoking behaviour
among the Swedish population. In 1980, 36% of the
men and 33% of the women were daily smokers; the
corresponding figures 20 years later were 17% for
men and 19% for women.
The primary objectives of the present paper were
(a) to estimate healthcare cost and productivity
losses in Sweden 2001 due to the smoking of
cigarettes and (b) to compare our results with the
previous study for Sweden in 1980 [27]. In order to
do so, we consistently used the same "epidemiolo-
gical approach" and data from the same public
registers as the earlier study, as well as the apparently
best epidemiological evidence there is at present. A
secondary objective was to compare our results for
Sweden 2001 with recent studies from some other
countries, namely for Canada 1991 [30], Germany
1996 [31], and the USA 1998 [32].
Material and methods
Our study consistently followed the "epidemiologi-
cal approach", when employing a top-down meth-
odology to estimate the different cost components,
the human capital approach to place a monetary
value on lost productive life years, i.e., by using lost
gross annual income as the measure of lost produc-
tion during a person-year, and the epidemiological
attributable-risk methodology to estimate the share
of costs attributed to smoking [27,31,35,36].
First, we estimated the overall costs for age groups
35-84 of the most important diseases known to be
associated with smoking. The diseases were malig-
nant neoplasms in the upper aerodigestive tract,
lungs, pancreas, urinary bladder, and kidney;
chronic obstructive pulmonary disease (COPD)
and other respiratory diseases; ischaemic heart
disease, other heart disease, stroke, and arterial
disease [37]. For each of them and for all diseases,
healthcare cost (direct cost) and productivity losses
 Smoking, healthcare cost , and loss of productivity 189
(indirect cost) were calculated. Healthcare cost here
includes hospital care, ambulatory care, and drug
treatment. Indirect cost here includes productivity
losses due to permanent (longstanding) disability
and premature mortality. Owing to lack of suitable
data, productivity losses caused by short-term illness
could not be estimated.
Total number of all hospitalizations in Sweden by
disease category [38] and DRG (Diagnosis Related
Groups) unit costs for a representative sample of
Swedish hospitals [39] were used in order to
calculate the total hospital cost for the disease
categories studied. Total number of doctor's con-
sultations by disease category, based on a represen-
tative sample of Swedish doctors [40] and unit costs
from Stockholm county council, the largest county,
comprising a sixth of the Swedish population [41],
were used in order to calculate the total cost of
ambulatory care for the disease categories studied.
Data on prescriptions for a representative sample of
Swedish doctors [41] and sales figures for the
relevant pharmaceuticals [42,43] were used to
estimate the drug cost for the disease categories
studied.
Estimates of the number of life-years and produc-
tive life-years lost due to mortality or permanent
disability were based on data on total mortality and
total number of early retirements by medical condi-
tion, age, and sex [44,45] and relevant life tables [46] .
Following the human capital approach, the number of
lost productive life-years was translated into monetary
terms by multiplying with age- and sex-dependent
average annual wages, including employers' contribu-
tions to social insurance [47,48]. A monetary value
was imputed to household production, based on
surveys of household patterns of time use and data
on age- and sex-dependent wage rates, net of income
tax [49,50]. Present values of future earnings and
imputed household work were discounted at 5%, a
commonly used discount rate in Sweden.
Second , attributable (mortality) risks for current
smokers ( Ts ) and former smokers (7}5) were calcu-
lated, using the formulae [32]:
Ts= -, a¡-(R¡ - 1)
(ans + as "Rs + afs 'Rfs)
T = afs'{Rfs~ l) (/?,
^ = (&ns -'-as-Rs + afs • R/s )
where
as= share of smokers in the population,
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afs- share of former smokers in the popula-
tion,
ans= share of never-smokers in the popula-
tion,
Rs= relative mortality risk of smokers in the
population,
RfS= relative mortality risk of former smo-
kers in the population, and
Rns=l= relative mortality risk of never-
smokers in the population.
The share of smokers ( as ) in the Swedish population
was estimated on data from the Swedish Survey of
Living Conditions 1996-97. The share of former
smokers ( afS ) was estimated on data on the number
of quitters in the Swedish Survey of Living
Conditions between 1988-89 and 1996-97. By
definition, never-smokers constitute the rest of the
population, so (ans=l- as- afs). All shares were
estimated separately for men and women, and for
ages 35-64 and 65-84, respectively. The time lag
between data on smoking patterns (1988-97) and
study year (2001) was introduced in order to take
the decline in smoking prevalence rates into account
to some extent.
Estimates of relative risks for ages 35-84 were
taken from the most conservative of the results,
based on the large-scale US nationwide prospective
mortality study (CPS-II), i.e. after controlling for a
number of influencing factors besides age and sex
[37]. People who had given up smoking before
1988-89 and who were still alive in 1996-97 were
assumed to have the same mortality risks as never-
smokers, taking into account the fact that the impact
of past smoking behaviour declines with age. Before
the age of 35 and after the age of 84, smokers,
former smokers, and never-smokers were all
assumed to have the same mortality risks.
The estimates of attributable risks were used not
only to calculate the number of deaths attributable
to smoking in Sweden in 2001, but also - for lack of
any other relevant information - to calculate the
shares of direct and indirect cost attributable to
cigarette smoking for each smoking-related disease.
Results
Calculated attributable risk-rates for smokers and
former smokers, by sex and age, in Sweden 2001, are
presented in Table I.
A summary of the estimated impact of smoking,
including healthcare cost, productivity loss, lost life-
years, and lost productive years (due to mortality or
190 K. Bolin & B. Lindgren

ICD-9
Table I. Calculated attributable risks for smokers and former smokers in Sweden 2001, men and women, respectively, ages 35-64 and 65-
84 years, respectively.

35 - 64 years 65 - 84 years
Smokers Former smokers Smokers Former smokers
code(s) Men Women Men Women Men Women Men Women
Cancer
Upper aerodigestive tract 140-149, 0.54 0.53 0.13 0.07 0.47 0.37 0.11 0.05
150, 161
Trachea, bronchus, lung 162 0.72 0.70 0.13 0.07 0.67 0.56 0.12 0.07
Pancreas 157 0.21 0.23 0.02 0.04 0.15 0.13 0.01 0.02
Kidney 189 0.24 0.12 0.06 0.02 0.18 0.06 0.05 0.01
Urinary bladder 188 0.29 0.26 0.07 0.06 0.22 0.15 0.05 0.04
COPD 490-492, 496 0.56 0.64 0.19 0.15 0.50 0.51 0.17 0.13
Respiratory conditions

Other respiratory diseases 010-012, 0.16 0.24 0.04 0.01 0.12 0.13 0.03 0.01
480-487, 493

Cardiovascular conditions
Ischaemic heart disease 410-414 0.25 0.36 0.05 0.02 0.07 0.08 0.01 0.02
Other heart disease 390-398, 0.15 0.15 0.02 0.02 0.11 0.08 0.01 0.01
401-405,
415-417,
420-429
Stroke 430-438 0.24 0.42 0.00 0.02 0.07 0.07 0.00 0.01
Arterial disease 440-448 0.37 0.42 0.06 0.02 0.30 0.26 0.04 0.01

permanent disability) is given in Table II. The
estimated total cost was US$ 804 million, or USft
90 per capita, of which 26% was the healthcare cost.
The number of deaths was 79 per 100,000 inhabi-
tants; the number of lost life-years was 1,012 per
100,000 inhabitants; and the number of lost
productive years was 185 per 100,000 inhabitants.
Table IE presents estimated healthcare cost, pro-
ductivity loss, and the number of deaths for each
disease category. COPD and cancer of the lung
accounted for 43% of the total cost. Table IE also
reproduces estimated healthcare cost and the number
of deaths by disease category for Sweden 1985 [27].
Sensitivity analysis
All estimates provided are point estimates, but we
calculated some lower and upper limits for the
results depending on the assumptions made.
[37] were used. Using the lower limit of the
confidence intervals would lower the estimated cost
by 6%. Using the upper limit of the confidence
intervals would increase the estimated cost by 5%.
Unit costs. Unit costs were collected and calculated
from various sources: regarding the unit cost used in
the calculations of the monetary value of
productivity losses we used annual wages; unit
costs in the cases of hospitalizations and
consultations were collected from administrative
databases; unit costs involved in the calculation of
total drug costs are individual drug prices charged by
the Swedish National Corporation of Pharmacies. In
all these cases, the total cost is a linear combination
of physical resources and unit costs. Thus, if the
"true" unit costs were 10% higher (lower), the
estimated costs would have been 10% higher
(lower).

Discount rate. The base case discount rate was 5%. If

the "true" discount rate were 2.5%, the estimated
cost would have been 18% higher. If, on the other
hand, the "true" discount rate were 10%, the
estimated cost would have been 7% lower.
Relative ńsks. When attributable-risk rates were
calculated, the mean relative risks presented in
Discussion
The estimated cost of smoking depends on a number
of factors, which may change in strength over time
(or be different among countries), such as smoking
behaviour, healthcare technologies, non-healthcare
technologies, health insurance, and epidemiological
knowledge. Thus, every estimate is both time and

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 Smokings healthcare cost y and loss of productivity 191

Table II. Summary of the estimated impact of smoking in Sweden 2001 (current study) and 1980 [25], total and per 100,000 inhabitants.

Year 2001 Year 1980

Total Per 100,000 Total Per 100,000
Healthcare

Number of hospital stays 73,000 819 na -

Hospital care

Number of bed-days 570,000 6,398 447,000 5,374

Cost 155,000,000 1,737,500 134,000,000 1,612,000
Number of consultations 350,000 3,929 50,000 601
Ambulatory care

Cost 40,000,000 444,500 7,000,000 86,500

Cost 17,000,000 192,000 3,000,000 32,500
Pharmaceuticals

Number of deaths (35-84 years) 7,000 79 6,810 82

Mortality

Lost life-years 90,200 1,012 102,000 1,226

Lost productive life-years 11,900 134 23,500 283
Lost productivity 423,000,000 4,748,000 428,000,000 5,150,500
Permanent disability
Number of early retirements due to 1,200 13 1,000 12
Lost productive years 4,500 51 5,450 66
permanent disability

Lost productivity 169,000,000 1,899,000 111,000,000 1,331,000

Loss of productivity discounted by 5% (current study) and by 4% [25] - all costs in 2001 USft.

country specific. This becomes quite clear, when we
compare our results for Sweden in 2001 with those
previously found for 1980 (see Tables II and III). In
this case, differences in methods and data cannot
explain differences in results, since both studies used
the same methods and the same kind of data and
since both studies had to leave short-term sickness
out of the estimate owing to lack of sufficiently
detailed data. For purposes of comparison, all 1980
cost figures were translated into the 2001 general
price level in Sweden, using the Swedish Consumer
Price Index and converted into US dollars by using
the average exchange rate for 2001 [51]. To facilitate
comparisons, we also calculated the impact of
smoking per inhabitant and per smoker, 15 years
of age and older.
Certainly, smoking behaviour among the Swedish
population has changed. In 1980, 36% of the men
and 33% of the women were daily smokers; the
corresponding figures 20 years later were 17% for
men and 19% for women. These changes alone,
naturally, decreased the cost of smoking per inhabi-
tant.
As for advances in epidemiological knowledge, a
few, but not many, diagnoses were added in 2001:
cancer of the kidney, some respiratory condi-
tions beside COPD, some heart conditions beside
ischaemic heart disease, and - above all - stroke. In
addition, also through the improved epidemiological
knowledge, the risk for a smoker to die prematurely
was considered to be higher for each condition in
2001 than in 1980. Even if these changes do not
alter the actual impact of smoking, they both
increase the estimated attńbutable ńsks. So, even
though the prevalence of smoking decreased in
Sweden between 1980 and 2001, the estimated cost
increased.
The most striking change in the impact of
healthcare technologies seems to be the decline in
the number of deaths, as well as in productivity loss
and healthcare cost, for ischaemic heart disease.
Thus, even though the estimated percentage of the
cost for ischaemic heart disease attributable to
smoking increased in accordance with the conclu-
sion above, the total cost due to ischaemic heart
disease fell more than enough to compensate for the
increase in percentage. Since 1980, there have been
a number of improvements in the treatment of
ischaemic heart disease. If they had not occurred,
the estimated cost of smoking would have been
considerably higher; if a similar breakthrough had
occurred in the treatment of COPD, the estimated
cost of smoking would have been considerably
lower.

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192 K. Bolin & B. Lindgren

Table HI. Estimated healthcare cost, productivity loss, and number of deaths in Sweden 2001 (current study) and 1985 [25] (productivity
loss for 2001 only) due to smoking, by disease category.

Healthcare Productivity Deaths Healthcare Deaths

ICD-9 code(s) cost in 2001 loss in 2001 in 2001 cost in 1985 in 1985
Cancer
Upper aerodigestive tract 140-149, 150, 161 13.2 44.6 445 10.1 192
Pancreas
Kidney 157 2.4
189 1.1 16.9
8.6 221 4.1 292
Trachea, bronchus, lung 162 24.5 164.8 2,174 32.0 1,572
98
Urinary bladder 188 4.4 6.3 113 5.5 101
COPD 490-492, 496 78.8 78.1 1,163 24.7 519
Respiratory conditions

Other respiratory diseases 010-012, 480-487, 13.3 8.4 156 -

493

Cardiovascular conditions
Ischaemic heart disease 410-414 30.4 165.7 1,475 46.2 3,834
Other heart disease 390-398, 401-405, 22.3 10.4 20
Stroke 430-438 8.9 53.6 273 415-417, 420-429

Arterial disease 440-448* 12.1 28.9 623 22.1 300

Loss of productivity discounted by 5% for 2001 and 4% for 1985; all costs in 2001 US$ million. a441, 443-445 in [25].

Productivity per hour worked increased between
1980 and 2001 as a result of improvements in non-
healthcare technologies, which implies an increase in
the loss of total productivity, ceteris paribus. True,
the estimated number of deaths remained
unchanged, but deaths occurred later in life, so both
the number of lost life-years and the number of lost
productive life-years decreased substantially. Early
retirements due to illness had a similar development
- they increased in number by 20% but decreased in
terms of lost productive years by 17% owing to the
fact that early retirements occurred at older ages.
Despite that, the loss of productivity due to mortality
and permanent disability increased by 10%. That
deaths and early retirements occurred later in life
may also be an outcome of improved healthcare
technologies.
Table IV reproduces results from some selected
studies [30-32] and some complementary data [52-
54] for Canada, Germany, and the United States as
well as for the two Swedish studies. There is a
striking difference both in costs and in attributed
deaths due to smoking between Sweden on one hand
and the three other countries on the other. Our
estimated percentage of all deaths attributed to
smoking was substantially lower; the same goes for
the percentage of the total healthcare cost attributed
to smoking, the cost per capita, and the cost per
smoker.
According to Table IV, fewer Swedes are regular
smokers, and they do not smoke with the same
intensity; according to available data, a smoker in
Sweden seems to smoke 15-16 cigarettes per day,
while smokers in Canada, Germany, and the USA
seem to smoke 23-24 cigarettes per day on average.
Swedes may even smoke for a shorter duration. The
cumulative effect of that would cause the overall
mortality rates for lung cancer, heart disease, etc. to
be lower than in other countries. Also the general
heart disease mortality rate may be lower in Sweden,
if, for instance, Swedes have better nutrition and
more physical activity, and if they invest more in
early detection and prevention of smoking-related
disease and death. As a matter of fact, Sweden does
have the lowest lung cancer death rate in men among
the European countries and has had among the
lowest for a long time [55]. Sweden also has a
relatively moderate heart disease mortality rate
compared with other countries [56]. Thus, even
though we used the relative risks of mortality found
in a large-scale US study [37], mortality attributed
to smoking was lower in Sweden for two reasons: (a)
lower cigarette smoking prevalence rates, which
lower the calculated attributable risks, and (b) lower
overall mortality in the relevant disease categories,
which lowers the number of deaths attributed to
smoking for a given attributable risk.
In addition, Swedish smokers seem to die at a
higher age, which means that the loss of productivity
tends to be lower.
In addition, both earnings per hour and healthcare
cost per capita are lower in Sweden than in the other

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 Smoking , healthcare cost , and loss of productivity 193

Table IV. Economic impact of smoking according to some selected studies from various countries and time periods: Comparisons with the
present study regarding prevalence rates, number of conditions included, cost items included, and percentage of all deaths attributed to
smoking.

Percentage Smoking prevalence

of rates, 15 years of Consumption
Cost per Cost per healthcare Percentage age and over of cigarettes
capita smoker cost of deaths (percentages): per smoker, No. of No. of cost
First Country, (2001 (2001 attributed attributed to
author study year US ft) US ft) to smoking smoking men women age and over (more/less) (more/less)
(current Sweden 90 600 1.5 7 17 19 5,960 - -
study) 2001
H j alte [25] Sweden 82 300 1.2 7 36 33 5,360 less same
1980
Kaiserman Canada 396 1,600 3.8 20 31 29 8,345 more more
[28] 1991
Ruff [29] Germany 249 1,100 3.7 16 33 20 8,805 less same
1996
CDC [30] USA 1998 579 3,200 8.0 21 26 21 8,890 more same
When calculating loss of productivity 4% or 5% discount rates used. Information on smoking prevalence rates and consumption of
cigarettes from [50-52]. All costs in 2001 USft.

countries in Table IV. This is certainly true for a
given year, but may also be true when comparisons
are made between different years. The USA in 1998,
for instance, had substantially higher earnings per
hour than Sweden in 200 1 . Higher earnings per hour
increase lost productivity, and a larger healthcare
cost in general also increases the healthcare cost
attributed to smoking, ceteris paribus.
All studies used the human-capital approach, i.e.
they used the annual gross income and the number
of lost productive years in order to estimate the loss
of productivity for an early-retired person. The
friction-cost approach has been suggested as an
alternative to the human-capital approach [57].
According to the friction-cost approach, productivity
losses occur during the time it requires to replace an
employee who has been struck by disease and
disability. The friction period might yield estimates
that are higher or lower than the human-capital
approach. It has no firm foundation in economic
theory, however [58], so its conclusions depend
solely on empirical estimates. There are no empirical
estimates of the length of friction periods in Sweden
to guide us in such an alternative estimate, nor do
the country studies from Canada, Germany, or the
United States provide such (and comparable)
estimates.
All studies also excluded from the estimates the
costs of the informal care provided by relatives or
friends. Although such costs may be substantial, it is
impossible to tell to what extent this bias would
affect the country comparisons.
There are also some methodological differences
between the studies. While all five used the
"epidemiological approach" to calculate mortality
attributed to smoking and to estimate lost produc-
tivity, the American and Canadian studies used the
"econometric approach" to estimate healthcare cost
due to smoking, i.e. they ran multiple-regression
analyses on personal healthcare expenditure data
that include information on factors besides smoking
that may affect healthcare expenditure, such as other
risk behaviours, socioeconomic status, and demo-
graphic characteristics. This does not necessarily
mean that the econometric approach produces
consistently higher estimates. The CDC study
estimate is well in the 6-14% range of other
American studies, some of which were performed
with the epidemiological approach [59,60].
The number of health conditions covered also
differs between studies. The American [32] and the
Canadian [30] studies also included infant mortality
due to mothers' smoking (0.2% of total mortality in
the United States [32]) as well as fire deaths and
cancer and heart disease deaths due to passive
smoking (8.6% of total mortality in the United
States [32]). On the other hand, the German study
included fewer conditions [31]. No study so far,
though, has claimed that it covered the "true" or
"full" economic cost of smoking. Even though
differences in the estimates, indeed, to some extent
are due to methodological differences, a substantial
share of the difference seems to be real.
Attributable risks calculated for mortality were
used also to distribute healthcare cost and produc-
tivity loss due to permanent disability by disease
categories. Some would argue that this implies a
(considerable) underestimate of the true cost, since

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194 K. Bolin & B. Lindgren
it does not recognize the fact that smoking may have
an impact on health, productivity, and healthcare
without being lethal, or how smoking may compli-
cate the course of many diseases that are not
themselves directly associated with smoking
[60,61]. This may well be the case but, on the other
hand, some smoking-related conditions may be
more rapidly fatal, and there may exist less effective
treatments for these conditions, leading to lower
healthcare consumption than for other conditions. A
person who dies during surgery will consume less
healthcare than the one who survives the operation.
The issue above has not yet been resolved. The
problem with the econometric approach, which has
been standard in recent years in the USA for
estimating the impact of smoking on healthcare
cost, is that it easily overestimates the impact, since
smokers take more risks in general - and not only
with regard to smoking - than non-smokers [62].
Smokers drink more alcohol, they exercise less, and
they even drive closer to the car in front of them.
Thus, the analyst has to make sure that he or she
captures all other factors than smoking that may
have an influence on healthcare consumption (and
on short-term morbidity and permanent disability).
No one probably knows presently what all these
factors are and, even if one knew, they may not be
reported in available datasets. In Sweden, there are
no datasets of personal healthcare expenditures
available, the main reason probably being that there
is no need to bill individual patients in their county-
council tax-financed healthcare delivery system.
Even though the figures presented here for
Sweden are remarkably low in comparison with
some other countries, to reduce smoking is still a
public-health-policy issue worth pursuing in Sweden
as in all countries. In order to reduce the cost of
smoking, however, the lesson from the comparisons
seems to be that policy-makers should show a
substantial interest also in the factors that determine
the cost per smoker. The estimated costs per smoker
were USft 3,200 in the USA in 1998, USft 1,600 in
Canada in 1991, US$ 1,100 in Germany in 1996,
USft 600 in Sweden in 2001, and US$ 300 in
Sweden in 1980 (all in 2001 USft prices). While the
prevalence rate was 25% higher, the cost per smoker
was more than 400% higher in the USA than in
Sweden. The implication of these estimates certainly
makes policy-making generally more complex.
Acknowledgements
The authors are grateful to Göran Boethius
(Östersund Hospital); Hans Gilljam (Swedish
Centre for Tobacco Prevention); Bengt Haglund
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and Mans Rosen (both at the Epidemiological
Centre of the Swedish National Board of Health
and Welfare); Lars Lindholm (Umeá University);
Monica Ribohn (Moleri pic); and Gunnel Boström,
Margaretha Haglund, Barbo Holm Ivarsson, Anna
Mânsdotter, Paul Nordgren, and Gunnar Âgren (all
at the Swedish National Institute of Public Health)
for valuable comments and helpful suggestions on a
preliminary report in Swedish. They also thank Jane
Henley, Omar Shafey, and Michael Thun of the
American Cancer Society, Gary Giovino of the
Roswell Park Cancer Institute, and Kenneth
Warner of the University of Michigan, for their
advice and support during the whole project and
their colleagues Sören Höjgärd, Carl Hampus
Lyttkens, Louise Roberts, and Katarina Steen
Carlsson, as well as two anonymous reviewers, for
their very useful comments and suggestions on
earlier versions of this paper. The financial con-
tribution from the Swedish National Institute of
Public Health is also gratefully acknowledged.
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