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The Burden of Tobacco-Related Diseases andHealth Care Costs of Tobacco Use in the Philippines. Marina Miguel-Baquilod, MD, MSc Country Research Coordinator, Tobacco and Poverty Study Department of Health, Manila . Background.

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The burden of tobacco related diseases and health care costs of tobacco use in the philippines l.jpg

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

Marina Miguel-Baquilod, MD, MSc

Country Research Coordinator,

Tobacco and Poverty Study

Department of Health, Manila


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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


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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

Collaborative Study Group


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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)


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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)


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Health Expenditures, Selected Western Pacfic Countries, 2002

Source: National Statistical Coordination Board, 2004


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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).


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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).


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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).


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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.


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Estimation of Disease Burden (Method 1)

Population Attributable Risk

where

AB= attributable burden for a given risk factor and population

AFj= fraction of the burden from cause j

Bj = estimated population-level burden from cause j

P = prevalence of the exposure

RRj= relative risk of disease or injury from cause j in the exposed group compared to the unexposed group


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Estimation of Disease Burden (Method 1)

Smoking Impact Ratio

CLC= Age-sex specific lung cancer mortality rate in a population

NLC= Age-sex specific lung cancer mortality rate of never-smokers in the same population

S*LC and N*LC = Age-sex specific lung cancer mortality rates for smokers and never-smokers in a reference population


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Estimation of Disease Burden (Method 1)

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


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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 group

P1=Percentage of adult current smokers in study group

P2=Percentage of adult former smokers in study group

RR1=Relative risk of death for adult current smokers relative to adult never smokers

RR2=Relative risk of death for adult former smokers relative to adult never smokers


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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


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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

    interventions

    3. Priority setting

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


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DALY = YLL + YLD

Where:

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.


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Parameters for DALY Estimation-

  • Use of the spreadsheet model of Murray et. al. by triangulating data from various sources

    (sensitivity analysis):

    • Number of incident cases

    • Number of deaths

    • Number of cases with disabling sequelae

    • Duration of disability

    • Disability weights

    • Life expectancy

    • Age weighting

    • Discount rate


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Estimation of Burden (DALY)


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Estimation of Burden (DALY)


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Estimation of Burden (DALY)

Limited to four disease attributable to smoking namely:

  • Lung cancer

  • Chronic obstructive pulmonary disease (COPD)

  • Cerebro-vascular disease (CVD)

  • Coronary artery disease (CAD)


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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


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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).


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Results

*Data from NNHeS

Dans et al, 2005


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Results


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Results

*Using SAMMEC methodology


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Results

**Using Peto-Lopez methodology


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Results

*Using SAMMEC methodology


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Results

**Using Peto-Lopez methodology


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Results


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Results


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Results

*Using SAMMEC Methodology


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Results

**Using Peto-Lopez Methodology


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Results

*Using SAMMEC Methodology figures


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Results

**Using Peto-Lopez Methodology figures


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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


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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


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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


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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


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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.


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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.


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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

Acknowledgments


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MARAMING SALAMAT!

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