The Burden of Tobacco-Related Diseases and Health Care Costs of Tobacco Use in the Philippines Marina Miguel-Baquilod, MD, MSc Country Research Coordinator,

The Burden of Tobacco-Related Diseases andHealth Care Costs of Tobacco Use in the Philippines

Marina Miguel-Baquilod, MD, MScCountry Research Coordinator,

Tobacco and Poverty StudyDepartment of Health, Manila

Background

Project: “Tobacco and Poverty Study” in the Philippines

Component Studies:

1. Prevalence of Tobacco Use

2. Household Expenditures and Tobacco Use

3. Burden of Tobacco-Related Diseases in the Philippines

4. Analysis of Demand for Tobacco in the Philippines

Collaborative Study Group

Dept. of Health- Dr. Marina M. Baquilod- Dr. Ernie V. Vera- Dr. Elizabeth R. Matibag

WHO-TFI, HQ- Dr. Ayda A. Yurekli

College of Public Health-University of Philippines, Manila

- Mr. Alvin G. Tan- Prof. Marilyn E. Crisostomo .- Dr. Jesus Sarol- Dr. Jane C. Baltazar

Demographic and Economic Profile, Republic of the Philippines

Population (2007) 88.7M Population of 15-64y.o.=59.2% of Total

Popn. Life Expectancy at birth, Projected

2007 (Male=66.11yrs; Female=71.64yrs) Annual Growth Rate=2.4% Poverty Incidence (2003)= 27.4% of

Families Unemployment (Jan.2007) 7.8% Ave. Family Income (2003) P147,888

(U$2,640) Ave. Family Expenditures (2003)

P123,693 (U$2,208) GNP (Q4’06)Php1,856.0B (U$37B) GDP (Q4’06)Php1,693.6B (U$34B)

Health and Nutrition Status, 2003

Infant Mortality Rate =30.0/1,000 Livebirths

(Low/ High Income Ratio=2.16) Chronic Undernutrition = 30% of children (0-5yrs old) 6 of Top Leading Causes of Mortality were NCD’s

(past 20yrs): Diseases of Heart and Vascular System, Cancers, COPD, Diabetes, and Kidney Diseases

Prevalence of Tobacco use, 34.8%

(Male=56.5%; Female=12.1%),

(Low/High Income Ratio=2.51)

Health Expenditures, Selected Western Pacfic Countries, 2002

0102030405060708090

Per

cen

t

Total exp. On health as % of GDP

Gen. govt. exp. On health as % of total exp. On health

Private exp on health as % of total exp. On health

Source: National Statistical Coordination Board, 2004

7

Rationale of the Study

In 1995, the World Bank, estimated the number of smokers to be 1.1 billion smokers worldwide and projected it to rise to 1.6 billion by 2025 (Jha and Chaloupka, 1999).

In low- and middle-income countries where, an estimated 930 million smokers belong, cigarette consumption has been noted to increase (Jha et al, 2002).

Rationale

Known to be associated with a number of medical and non-medical causes of death and disability (US DHHS, 2004; English et al, 1995; Doll et al, 2004), half of all smokers will eventually die prematurely because of their habit.

Half of these deaths occur in the middle age (39-65 years) and lose 20 to 25 years of productive life (Jha and Chaloupka, 1999).

It was estimated that in the year 2000, about 4.83 M premature deaths in the world would be attributable to smoking (Ezzati and Lopez, 2003).

Rationale

A significant number adult Filipinos (15yrs and above) currently smoke cigarettes or use any tobacco product (NNHeS1998, 2003; BRFS 2001); Prevalence of current tobacco use ranks next to China and Indonesia (Tobacco Atlas, 2003)

A considerable number of Filipino youth initiated to

tobacco use; current smoking among girls had increased significantly (GYTS 2000, 2003).

Objectives

General objective: To determine the burden of disease attributable to smoking.

Specific objectives: Determine the health impact attributable to tobacco-

related diseases; Determine the economic impact attributable to tobacco-

related diseases.

Estimation of Disease Burden (Method 1)

jjBAFAB where

1)1(

)1(

j

jj RRP

RRPAF

AB= attributable burden for a given risk factor and populationAFj= fraction of the burden from cause jBj = estimated population-level burden from cause jP = prevalence of the exposure RRj= relative risk of disease or injury from cause j in the exposed group compared to the unexposed group

Population Attributable Risk


LC

LC

LCLC

LCLC

N

N

NS

NCSIR

*

***

CLC= Age-sex specific lung cancer mortality rate in a populationNLC= Age-sex specific lung cancer mortality rate of never-smokers in the same populationS*LC and N*LC = Age-sex specific lung cancer mortality rates for smokers and never-smokers in a reference population

Smoking Impact Ratio


2

11* RR

RR

To correct for potential confounding, Murray and Lopez used this modified formula for the Relative Risk:

Estimation of Disease Burden (Method 2)SAF = [(p0 + p1(RR1) + p2(RR2)) - 1] /

[p0 + p1(RR1) + p2(RR2)]

P0=Percentage of adult never smokers in study groupP1=Percentage of adult current smokers in study

groupP2=Percentage of adult former smokers in study groupRR1=Relative risk of death for adult current smokers

relative to adult never smokersRR2=Relative risk of death for adult former smokers

relative to adult never smokers

Global Burden of Disease Study (1992): WHO & World Bank

To provide an objective assessment of health status that is comparable across countries

Address limitations of available health statistics

Disability Adjusted Life Years (DALY) as indicator

DALY

Measure of burden of disease as the gap between current health status and an ideal situation where people live to old age free of disease and disability.

Used for: 1. Measuring the health impact of a disease 2. Analyzing cost-effectiveness of alternative

interventions3. Priority setting

Combines life lost due to premature death with life years lost due to living in a disabled state.

DALY = YLL + YLDWhere:

YLL = Years of Life Lost or amount of time in years lost due to premature death from a specific disease.

YLD = Years Lived with Disability or the period of time someone has to live suffering from a disability brought about by a specific disease.

Parameters for DALY Estimation- Use of the spreadsheet model of Murray et. al. by

triangulating data from various sources

(sensitivity analysis):

1. Number of incident cases

2. Number of deaths

3. Number of cases with disabling sequelae

4. Duration of disability

5. Disability weights

6. Life expectancy

7. Age weighting

8. Discount rate

Estimation of Burden (DALY)

Data points Data sources

1. Age and sex specific mortality rates NSO, DOH

2. Age and sex specific morbidity rates

DOH3. Age and sex specific lung cancer mortality rates

for non-smokers

4. Age and sex specific lung cancer mortality rates for smokers and non-smokers

Review of literature (CPS-II, Liu et al, 1998)

5. Smoking prevalence 2002 National Nutrition and Health Survey


Data points Data sources

5. Case fatality rates

Review of literatureExpert interviews

6. Proportion of cases who develop sequelae

7. Disability days


Limited to four disease attributable to smoking namely: Lung cancer Chronic obstructive pulmonary disease (COPD) Cerebro-vascular disease (CVD) Coronary artery disease (CAD)

Estimation of Burden (Costs)

combination of review or records, literature review, and expert interviews.

Perspective-societal Direct medical costs: hospitalization, out-patient

consultations, diagnosis, treatment and rehabilitation costs

Direct non-medical costs (salaries of watchers, transportation costs, etc) were not included

Philippine Health Insurance Corporation (PHIC) provided another data source for hospitalization costs

Estimation of Burden (Costs)

Productivity losses due to premature deaths- years of life lost (YLL) with the daily* minimum wage (P325) projected to 20 years

Productivity losses due to the disease were estimated using work days lost due to the four diseases as reported by Dans and colleagues (unpublished).

ResultsTable 1. Age-Sex Specific Prevalence of Smoking in the Philippines 2002*

Age groupsNever Smokers Current Smokers Ex-Smokers

Male Female Male Female Male Female

20-29 34.5 89.0 58.8 7.3 6.7 3.7

30-39 31.9 89.1 54.2 8.5 14.0 2.4

40-49 25.4 83.4 61.0 12.1 13.6 4.6

50-59 15.8 79.6 59.5 16.1 24.7 4.4

60-69 19.4 64.9 48.6 23.8 32.1 11.3

70+ 22.4 60.2 35.9 22.4 41.8 17.5

All Age Groups 28.6 82.8 56.3 12.1 15.1 5.1

*Data from NNHeSDans et al, 2005

Results

Table 2. Projected Mortality for Four Smoking-related Diseases, 2003

DiseaseProjected Mortality

Male Female Total

Lung Cancer 4,490 1,383 5,873

Cerebro-Vascular Disease 18,513 13,082 31,595

Coronary Artery Diseases 18,302 10,257 28,559

COPD 9,366 4,088 13,454

All four diseases 36,580 23,075 79,481

Results

Table 3a. Smoking Attributable Mortality for Four Smoking-related Diseases, 2003*


Male Female Total

Lung Cancer 4,150 952 5,102



COPD 7,947 2,903 10,850


*Using SAMMEC methodology

Results

Table 3b. Smoking Attributable Mortality for Four Smoking-related Diseases, 2003**


Male Female Total

Lung Cancer 3,711 596 4,307

Cerebro-Vascular Disease 5,076 778 5,854

Coronary Artery Diseases 4,567 817 5,384

COPD 5,973 1,732 7,705


**Using Peto-Lopez methodology

Results

Table 4a. Smoking Attributable Morbidity (Incidence) for Four Smoking-related Diseases, 2003*

DiseaseProjected Morbidity

Male Female Total

Lung Cancer 6,140 1,408 7,548



Chronic Obstructive Pulmonary Disease 80,273 29,323

109,596


*Using SAMMEC methodology

ResultsTable 4b. Smoking Attributable Morbidity (Incidence) for Four Smoking-related Diseases, 2003**

DiseaseProjected Morbidity

Male Female Total

Lung Cancer 5,490 882 6,372



COPD 60,331 17,492 77,823


**Using Peto-Lopez methodology

Results

Table 5a. Comparison of Smoking Attributable Fractions (SAF) Using SAMMEC and Peto-Lopez Methodology for Four Smoking-related Diseases, Males

DiseasesSAMMEC Peto-Lopez

35-64 65+ 35-64 65+

Lung Cancer 93% 92% 88% 75%

CVD 56% 22% 38% 7%

CAD 53% 23% 43% 8%

COPD 87% 86% 76% 57%

Results

Table 5b. Comparison of Smoking Attributable Fractions (SAF) Using SAMMEC and Peto-Lopez Methodology for Four Smoking-related Diseases, Females

DiseasesSAMMEC Peto-Lopez

35-64 65+ 35-64 65+

Lung Cancer 66% 77% 54% 37%

CVD 32% 11% 21% 3%

CAD 25% 14% 14% 3%

COPD 68% 78% 55% 38%

Results

Table 6a. DALYs for Four Smoking-related Diseases, 2003*

Diseases YLL YLD DALYs

Lung Cancer 59,723 935 60,658

CVD 139,664 690,694 830,357

CAD 128,783 251,004 379,787

COPD 109,540 63,736 173,276

All 4 Diseases 437,710 1,006,369 1,444,078

*Using SAMMEC Methodology

Results

Table 6b. DALYs for Four Smoking-related Diseases, 2003**

Diseases YLL YLD DALYs

Lung Cancer 19,048 1,157 20,205

CVD 87,277 103,344 190,621

CAD 83,962 225,292 309,254

COPD 84,976 47,205 132,181

All 4 Diseases 275,263 376,998 652,261

**Using Peto-Lopez Methodology

Table 7. Comparison between DALYs from Smoking- Related Diseases and TB

SexSmoking

related diseases

/100000

TB/100000

Ratio (smoking

related diseases/TB

)

Male 1,119,291 2,719

362,912

880 3.08

Female324,79

2799

151,388

373 2.15

Both 1,444,078 1,765

514,300

629 2.81

Results

Table 8a. Summary of Economic Costs in US$ for Four Smoking-related Diseases, 2003 ($1=PhP 52)*

Smoking-related Diseases

Health Care Costs

Productivity Losses from

Death


DiseaseTotal Costs

Lung Cancer 9,188,871 189,709,987 3,407,151 202,306,009

CVD 507,315,052 2,930,533,343 38,910,556 3,476,758,951

CAD 236,888,476 1,312,836,695 88,922,515 1,638,647,686

COPD 104,561,119 569,530,925 54,043,648 728,135,692

All 4 Diseases 857,953,518 5,002,610,950 185,283,871 6,045,848,339

*Using SAMMEC Methodology figures

Results

Table 8b. Summary of Economic Costs in US$ for Four Smoking-related Diseases, 2003 ($1=PhP 52)**

Smoking-related Diseases

Health Care Costs


Death


DiseaseTotal Costs

Lung Cancer 7,757,219 65,386,964 2,930,573 76,074,756

CVD 287,184,325 650,886,599 23,346,624 961,417,548

CAD 132,253,217 1,080,958,812 54,319,605 1,267,531,634

COPD 74,247,782 435,915,076 39,981,490 550,144,348

All 4 Diseases501,442,544 2,233,147,450 120,578,293 2,855,168,287

**Using Peto-Lopez Methodology figures

Discussion

Limitations• Only four of the 40 known diseases to be caused by

smoking were studied • Morbidity of the disease was probably underestimated

using indirect estimation• Morbidity and mortality estimates did not include those

for cigar smokers, passive smokers, pregnant women, and children

• Minimum wage was used to estimate productivity losses

• General picture of disease burden

Discussion

Higher estimates compared to Dans steady increase of mortality rates from the four diseases

studied increasing population

YLL=437,710 (53.49/10,000) Dans PYLL=125,918 (16.85/10,00) 3.17 times Dans estimate

Discussion

DALYs from lung cancer and COPD mainly YLL high case fatality ratio for lung cancer

CVD and CAD DALYs mainly YLD. The long duration of CAD and CVD sequelae and their

relatively low case fatality ratios

Discussion

Cost estimates Low=$2.86 B (Php148.72 B) High=$6.05 B (Php314.6 B) Dans Estimate= $891 M (Php46 B) GNP = Php 1,441.6B (2005 Q3) GDP= Php 1,322.4B (2005 Q3) Total Health Expenditure = Php165.2 B

Conclusions

DALYs range from 652,261 to 1,444,078 Different composition of DALYs Cost estimates range from $2.86 B to $6.05 B Over half of cases of the 4 major diseases were

attributable to smoking, hence, the significance of sustaining or strengthening comprehensive national tobacco prevention and control programs.

Policy Recommendations

Enforcement of the significant provisions of the Tobacco Regulatory Act of 2003 (RA 9211) and Framework Convention on Tobacco Control (FCTC)

Appropriation of budget, “Dedicated Taxes” as provided for in the “Sin Tax Law” (RA 9334), annual earmarking of 2.5% of revenues from tobacco excise tax since 2005 for disease prevention and control, focus on tobacco control and healthy lifestyle programs; and another 2.5% for Philippine Health Insurance, to increase coverage especially of indigent or poor families.

Strengthened comprehensive tobacco control programs that should prevent youth and poor people from uptake (taxation), available and accessible smoking- cessation programs, and strict environmental policies and regulations to prevent second-hand exposure to tobacco smoke.

Acknowledgments Tobacco Free Initiative, WHO, HQ- Dr. Anne- Marie Perucic- Dir. Douglas Bettcher

WHO,WPRO- Mr. Burke Fishburn- Mr. Jonathan Santos

WR-Philippines-Dr. Jean-Marc Olive-Dr. John Juliard Go

DOH- Usec. Ethelyn Nieto- Director Eric Tayag- Director Yoly Oliveros- Director Maylene Beltran- Dr. Marvi Ala- Dr. Jessica de Leon

Other GO’s- NSO, NSCB, NEDA,

NTA, BIR

MARAMING SALAMAT!Support Tobacco-Free Philippines

Documents

The Burden of Tobacco-Related Diseases and Health Care Costs of Tobacco Use in the Philippines Marina Miguel-Baquilod, MD, MSc Country Research Coordinator,