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

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

2. 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

3. 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

4. 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)

5. 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)

6. Health Expenditures, Selected Western Pacfic Countries, 2002 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).

8. 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).

9. 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).

10. 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.

11. 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

12. 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

13. Estimation of Disease Burden (Method 1) To correct for potential confounding, Murray and Lopez used this modified formula for the Relative Risk:

14. 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

15. 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

16. 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.

17. 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.

18. 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

19. Estimation of Burden (DALY)

20. Estimation of Burden (DALY)

21. 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)

22. 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

23. 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).

24. Results *Data from NNHeS Dans et al, 2005

25. Results

26. Results *Using SAMMEC methodology

27. Results **Using Peto-Lopez methodology

28. Results *Using SAMMEC methodology

29. Results **Using Peto-Lopez methodology

30. Results

31. Results

32. Results *Using SAMMEC Methodology

33. Results **Using Peto-Lopez Methodology

35. Results *Using SAMMEC Methodology figures

36. Results **Using Peto-Lopez Methodology figures

37. 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

38. 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

39. 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

40. 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

41. 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.

42. 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.

43. 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

44. MARAMING SALAMAT! Support Tobacco-Free Philippines