PERSPECTIVE
`
`How Much Can the USA Reduce Health Care
`Costs by Reducing Smoking?
`
`Wayne Hall1,2*, Chris Doran3
`
`1 University of Queensland Centre for Youth Substance Abuse Research, Royal Brisbane and Women’s
`Hospital, Herston, Queensland, Australia, 2 National Addiction Centre, King’s College London, London,
`United Kingdom, 3 School of Human Health and Social Sciences, Central Queensland University, Brisbane,
`Queensland, Australia
`
`* w.hall@uq.edu.au
`
`Cigarette smoking causes a wide variety of preventable diseases [1]. Its prevalence has declined
`substantially since the first US Surgeon General’s report (from 43% in 1965 to 18% today), but it
`remains a leading cause of preventable death in the United States, where it is responsible for more
`than 480,000 deaths per year, including nearly 42,000 deaths from secondhand smoke exposure.
`Declines in the prevalence of smoking among US adults (18 years of age and older) have slo-
`wed in recent years, and very large disparities in tobacco use remain across groups defined by
`race, ethnicity, educational level, and socioeconomic status and across regions of the country.
`Moreover, thousands of young people start smoking cigarettes every day, and estimates predict
`that if smoking continues at the current rate among US youth, 5.6 million of today’s Americans
`younger than 18 years of age are expected to die prematurely from a smoking-related illness [1].
`The total economic cost of smoking in the US is estimated at more than $300 billion a year.
`This includes nearly $170 billion in direct medical care for adults and more than $156 billion
`in lost productivity due to premature death and exposure to secondhand smoke [2]. To offset
`some of this cost, state governments collect $25.8 billion each year from tobacco taxes and legal
`settlements [1]. How much can these costs be reduced by reducing smoking prevalence?
`In the current issue of PLOS Medicine, Light and Glantz quantify the extent to which lower
`rates of smoking in the US might translate into lower health care costs. They have estimated
`how much, on average, a 1% reduction in smoking prevalence in a US state was associated with
`reduced health costs in that state a year later. Light and Glantz used a regression analytic
`approach that took into account correlations between the time series and the effects of other
`differences between states that may influence state health care expenditure, e.g., population age
`structure, education, ethnic composition, and the prevalence of risky behavior (e.g., obesity,
`heavy alcohol use). They have also conducted sensitivity analyses to assess the effects on their
`results of unmeasured variables (e.g., black market tobacco), different ways of measuring smok-
`ing and different ways of statistically modelling the effects.
`Their results suggest that a 10% relative reduction in smoking prevalence between a state
`and the national average in one year was followed by an average $6.3 billion reduction (in 2012
`dollars) in health care expenditure the following year. Consistent with this finding, the states
`with the most rigorous tobacco control policies had a much lower smoking prevalence and
`lower health care expenditures than states that did not have these policies.
`Like all modeling studies, this one has its limitations, as acknowledged by the authors. First,
`their analysis used aggregate state data on tobacco smoking prevalence and health care costs.
`We cannot use their results to infer the savings in treatment for individual smokers who
`
`a11111
`
`OPEN ACCESS
`
`Citation: Hall W, Doran C (2016) How Much Can the
`USA Reduce Health Care Costs by Reducing
`Smoking? PLoS Med 13(5): e1002021. doi:10.1371/
`journal.pmed.1002021
`
`Published: May 10, 2016
`
`Copyright: © 2016 Hall, Doran. This is an open
`access article distributed under the terms of the
`Creative Commons Attribution License, which permits
`unrestricted use, distribution, and reproduction in any
`medium, provided the original author and source are
`credited.
`
`Funding: The authors received no specific funding
`for this work.
`
`Competing Interests: The authors have declared
`that no competing interests exist.
`
`Provenance: Commissioned; not externally peer
`reviewed
`
`PLOS Medicine | DOI:10.1371/journal.pmed.1002021 May 10, 2016
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`become nonsmokers. Second, their analysis probably underestimates the potential health sav-
`ings from reducing smoking by focusing on the short term savings over 1 to 2 y. This gives
`greatest weight to cardiovascular and those respiratory diseases with the most rapid reduction
`in risk after quitting smoking. Their analysis does not take account of the reductions in the risk
`of disease like lung and other cancers. As the authors note, it is much harder to estimate these
`longer term savings from reducing smoking prevalence, because these effects will also change
`the age structure of the population. Conversely, over the very long term, some analyses suggest
`that reducing smoking prevalence may increase health care costs because it allows more people
`to survive into old age [3]. Third, a focus on reductions in health care costs also underestimates
`the full economic savings from reducing smoking, such as improved productivity in former
`smokers of working age. This may balance the long-term health care costs of those who survive
`to old age. Fourth, the analysis uses US data and US estimates of specific health care costs.
`These apply to the unique health care system of a large, wealthy, and technologically advanced
`society. The results cannot therefore be straightforwardly used as estimates of the economic
`savings that may be achieved in countries with different economies, populations, and health
`care systems. Similar studies need to be done in countries with different health care systems
`and a much higher prevalence of cigarette smoking.
`Notwithstanding these limitations, the study shows that reducing population smoking prev-
`alence and the number of cigarettes smoked per day are expected to substantially reduce health
`care costs over the next year. This makes population-based tobacco control policies a very
`good form of health care and societal investment by governments. These policies have contrib-
`uted to reducing the smoking prevalence among adults in countries like Australia from 31% in
`1986 [4] to 13% in 2013 [5]. These policies are low cost and easy to implement [6]. Increasing
`taxes reduces smoking and raises government revenue; smoke free policies are widely sup-
`ported by the public in many countries and not expensive to enforce. The same is true for
`restrictions on tobacco industry promotion of cigarettes.
`The challenge for tobacco control advocates has been to persuade governments to enact
`these policies in the face of tobacco industry lobbying, legal challenges, and campaigns to man-
`ufacture doubt about the health risks of smoking and the need for tobacco control policies
`[7,8]. Tobacco control interventions continue to be under-utilized and under-funded in the
`US. The US$468 million allocated by the states amounts to a small fraction of the $3.3 billion
`the CDC recommends for all states combined [9]. It would take less than 13% of total state
`tobacco revenue to meet the CDC recommendations in every state. States that have imple-
`mented well-funded, sustained tobacco prevention programs continue to report significant
`progress, adding to the evidence that these programs work. Florida, with one of the longest
`running programs, recently reported reducing its high school smoking rate to 6.9% in 2015,
`one of the lowest ever reported by any US state [10]. Appropriate state expenditure would
`accelerate the decline in tobacco use in youth and adults and bring forward an end to the
`tobacco smoking epidemic while saving billions of dollars in avoidable health care costs [9,11].
`
`Author Contributions
`
`Wrote the first draft of the manuscript: WH. Contributed to the writing of the manuscript:
`WH CD. Agree with the manuscript’s results and conclusions: WH CD. Both authors have
`read, and confirm that they meet, ICMJE criteria for authorship.
`
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