1. Smoking related discharges, bed days and costs in the acute hospital sector Dr Fenton Howell HSE Tobacco Control Framework Implementation Group

2. Key findings In 2008 there were 974,054 discharges (35+), using 3.5 million bed days, costing €2.97 billion. Smoking attributable diseases accounted for –36,255 (3.7%) discharges –300,756 (8.7%) bed days –€ 280 (9.4%) million 95% of the smoking attributable diseases were accounted for by: Cardiovascular and Respiratory Diseases and Cancers.

3. Introduction Illness and disease associated with smoking give rise to costs for the individual, for society and for the health service. Health service related costs include smoking cessation services, primary care and acute care costs. It is estimated that health care costs related to smoking can involve between 5% and 15% of health care budgets in developed countries Little is known about the true costs to the health sector in Ireland of smoking.

4. Aims The aim of this study was to quantify the impact of smoking on the acute sector. –Number of discharges –Bed days used –Costs

5. Methods Age/gender specific smoking rates for current and ex-smokers: SLAN 07. International relative risks for 40+ smoking related diseases. Appropriateness formula calculated. Apply appropriateness proportions to HIPE data. HIPE data 2008: discharges, bed days and costs for those age 35+. HIPE data from Health Research & Information Division, ESRI. Abstracted using Health Atlas Ireland.

6. Smoking rates SLAN 2007 Percentage MalePercentage Female CurrentEx-smokerCurrentEx-smoker 35+ yrs 25.829.923.618.9 45+ yrs 20.834.821.619.6 35-54 yrs 31.224.729.418.0 55-64 yrs 20.232.621.718.6 65-74 yrs 18.039.911.821.4 75+ yrs 14.143.514.120.5 35-64 yrs 28.226.827.318.2 65+ yrs 16.541.212.821.0

7. Cancers caused by smoking. Internationally used relative risks MalesFemales Cancers caused by smokingCurrent RREx RR Current RREx RR Lip, oral cavity, pharynx10.893.45.082.29 Oesophagus6.764.467.752.79 Stomach1.961.471.361.32 Pancreas2.311.152.251.55 Larynx14.66.3413.025.16 Trachea, Bronchus, Lung23.268.712.694.53 Cervix Uterin/a 1.591.14 Kidney and Renal Pelvis2.51.71.401.10 Urinary bladder3.272.092.221.89 Mal Neoplasm, unspec site4.42.52.201.30 Myeloid Leukaemia1.81.41.201.30

8. Attributable percentages calculated a = [pcur(rcur-1) + pex(rex-1)]*100 / [1+pcur(rcur-1) + pex(rex-1)] a = attributable percentage for each disease, pcur = proportion of current smokers, pex = proportion of ex smokers, rcur = relative risk of current smokers rex = relative risk of ex smokers Analysed using Excel

9. Cancers caused by smoking: attributable % MalesFemales Lip, oral cavity, pharynx76.6%54.7% Oesophagus71.6%65.9% Stomach28.0%12.7% Pancreas27.7%28.5% Larynx83.6%78.4% Trachea, Bronchus, Lung88.9%77.4% Cervix Uteri0.0%14.2% Kidney and Renal Pelvis37.4%10.2% Urinary bladder47.7%31.3% Mal Neoplasm, unspec site57.0%25.4% Myeloid Leukaemia24.6%9.4%

10. CVD caused by smoking: attributable % AgeMalesFemales Ischaemic Heart Dis35-5455.5%60.8% Ischaemic Heart Dis55-6433.3%29.0% Ischaemic Heart Dis65-7421.1%14.7% Ischaemic Heart Dis75+9.1%8.9% Other Heart disease35+21.1%12.4% Cerebrovascular Dis35-5452.0%57.4% Cerebrovascular Dis55-6431.4%39.1% Cerebrovascular Dis65-7420.7%20.2% Cerebrovascular Dis75+11.4%4.1% Atherosclerosis35+32.0%16.4% Aortic Aneurysm35+66.3%62.0% Other Arterial Disease35+21.8%23.0%

11. Respiratory and other diseases caused by smoking: attributable % AgeMaleFemale Pneumonia, Influenza35-6434.6%47.9% Pneumonia, Influenza65+24.8%14.9% Bronchitis, Emphysema35+89.5%82.3% Chronic Airway Obstruction35+80.8%79.8% Stomach Ulcer, Duodenal Ulcer35+57.9%53.2% Crohn's disease35+22.1%20.6% Peridonitis35+49.2%45.3% Cataract45+13.1%12.1% Hip #55-643.9% Hip #65-749.7%6.1% Hip #75+14.4%14.2% Spon AbortionAll0.0%6.2%

12. Methods Age/gender specific smoking rates for current and ex-smokers: SLAN 07. International relative risks for 40+ smoking related diseases. Appropriateness formula calculated. Apply appropriateness proportions to HIPE data. HIPE data 2008: discharges, bed days and costs for those age 35+. HIPE data from Health Research & Information Division, ESRI. Abstracted using Health Atlas Ireland.

13. Cardiovascular Disease DischargesBed daysCosts Male All Cardiovascular Disease (CVD) 39,349286,442€ 308 million CVD caused by smoking 32,381 264,228€ 287 million CVD attributable to smoking 8,527 65,888€ 79 million Attributable percentage 21.7%23.0%25.7% Female All Cardiovascular Disease (CVD) 27,663223,184€ 186 million CVD caused by smoking 19,988199,087€ 164 million CVD attributable to smoking 3,570 31,608€ 30 million Attributable percentage 12.9%14.2%16.3%

14. Cancers DischargesBed daysCosts Male All Cancers46,123237,080€ 254 million Cancers caused by smoking11,87788,047€ 94 million Cancers attributable to smoking 6,94855,805€ 55 million Attributable percentage15.1%23.5%21.9% Female All Cancers49,398224,113€248 million Cancers caused by smoking8,30560,196€ 62 million Cancers attributable to smoking 3,45226,892€ 26 million Attributable percentage7.0%12.0%10.4%

15. Respiratory Disease DischargesBed daysCosts Male All Respiratory Disease (RD)20,554182,840€ 132 million RD caused by smoking10,350105,657€ 75 million RD attributable to smoking6,41760,136€ 43 million Attributable percentage31.2%32.9%32.8% Female All Respiratory Disease (RD)19,365169,722€ 117 million RD caused by smoking9,02694,630€ 65 million RD attributable to smoking5,33850,302€ 36 million Attributable percentage27.6%29.6%31.0%

16. Digestive diseases, Cataracts, Hip # and Spontaneous Abortion DischargesBed daysCosts Male Other diseases caused by smoking 3,10811,940€ 13 million Other diseases attributable to smoking 9744,917€ 5 million Attributable percentage31.3%41.2%38.5% Female Other diseases caused by smoking 5,58017,474€ 19 million Other diseases attributable to smoking 1,0295,027€ 5 million Attributable percentage18.4%28.8%26.3%

17. Combining males and females DischargesBed daysCosts CVD attributable to smoking12,09897,496 € 110 million Attributable percentage18.1%19.1%22.1% Cancers attributable to smoking 10,40082,697€ 81 million Attributable percentage10.9%17.9%16.2% RD attributable to smoking11,755110,438€ 80 million Attributable percentage29.4%31.3%31.9% All diseases attributable to smoking 36,255300,756€ 280 million Attributable percentage3.7%8.7%9.4%

18. Conclusions Smoking attributable diseases place a significant burden on the acute hospital sector In 2008, smoking attributable diseases account for: –36,255 discharges –300,756 bed days –€ 280 million Underscores the necessity to invest in cost effective prevention measures which would be a fraction of the above costs. Repeat analysis for subsequent years Need to quantify all healthcare costs associated with smoking