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Medical-Care Expenditures Attributable to Cigarette Smoking -- United States, 1993

Cigarette smoking is the most important preventable cause of morbidity and premature mortality in the United States; however, approximately 48 million persons aged greater than or equal to 18 years are smokers (1), and approximately 24 billion packages of cigarettes are purchased annually (2). Each year, approximately 400,000 deaths in the United States are attributed to cigarette smoking (3) and costs associated with morbidity attributable to smoking are substantial (4). To provide estimates for 1993 of smoking-attributable costs for selected categories of direct medical-care expenditures (i.e., prescription drugs, hospitalizations, physician care, home-health care, and nursing-home care), the University of California and CDC analyzed data from the 1987 National Medical Expenditures Survey (NMES-2) and from the Health Care Financing Administration (HCFA). This report summarizes the results of the analysis.

The NMES-2 is a population-based longitudinal survey of the civilian, noninstitutionalized U.S. population (5). A cohort of 35,000 persons in 14,000 households was selected for face-to-face interviews four times during February 1987-May 1988. Respondents provided data about sociodemographic factors, health insurance coverage, use of medical care, and medical-care expenditures. Information also was collected about self-reported health status and health-risk behaviors including smoking, safety-belt nonuse, and obesity. The Medical Provider Survey, a supplement to NMES-2, provided confirmation of self-reported medical-care costs and supplied information about costs that survey respondents were unable to report.

To estimate costs attributable to smoking, respondents were categorized as never smokers, former smokers with less than 15 years' exposure, former smokers with 15 or more years' exposure, and current smokers. First, the effect of smoking history on the presence of smoking-related medical conditions (i.e., heart disease, emphysema, arteriosclerosis, stroke, and cancer) was determined. Second, for each of the medical-care expenditure categories, the probability of having any expenditures and the level of expenditures were estimated as a function of smoking, medical conditions, and health status (6). All models controlled for age, race/ethnicity, poverty status, marital status, education level, medical insurance status, region of residence, safety-belt nonuse, and obesity. Data were weighted to project the estimated costs of smoking-attributable medical care to the noninstitutionalized U.S. population. These costs were then adjusted for 1993 by applying the category-specific smoking- attributable percentages to national health-care expenditure data for 1993 reported by HCFA (7). Nursing-home costs were estimated by applying the smoking-attributable percentage of hospital expenditures for persons aged greater than or equal to 65 years to total nursing-home expenditures reported by HCFA. Costs of smoking-attributable medical care also were categorized by source of payment (i.e., self pay, private insurance, Medicare, Medicaid, other federal, other state, and other).

In 1987, the total medical-care expenditures for the five expense categories reported on NMES-2 was $308.7 billion; of this total, an estimated $21.9 billion (7.1%) was attributable to smoking (Table_1). Hospital expenses accounted for most ($11.4 billion) costs attributable to smoking, followed by ambulatory physician care * ($6.6 billion) and nursing-home care ($2.2 billion). Public funding (i.e., Medicare, Medicaid, and other federal and state sources) paid for 43.3% of the medical-care expenditures attributable to smoking (Table_2). The distribution of expenditures by source of payment varied substantially by age group. For persons aged greater than or equal to 65 years, public funding accounted for 60.6% of smoking-attributable costs, compared with 31.2% for persons aged less than 65 years.

When the smoking-attributable percentages derived from NMES-2 were applied to HCFA national health-care expenditure data (6), estimated smoking-attributable costs for medical care in 1993 were $50.0 billion. Of these costs, $26.9 billion were for hospital expenditures, $15.5 billion for physician expenditures, $4.9 billion for nursing-home expenditures, $1.8 billion for prescription drugs, and $900 million for home-health-care ** expenditures.

Reported by: JC Bartlett, MPH, School of Public Health, LS Miller, PhD, School of Social Welfare, Univ of California-Berkeley; DP Rice, ScD, WB Max, PhD, Institute for Health and Aging, Univ of California-San Francisco. Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion; Public Health Practice Program Office, CDC.

Editorial Note

Editorial Note: The findings in this report indicate that cigarette smoking accounts for a substantial and preventable portion of all medical-care costs in the United States. For each of the approximately 24 billion packages of cigarettes sold in 1993, approximately $2.06 was spent on medical care attributable to smoking. Of the $2.06, approximately $0.89 was paid through public sources.

From 1987 to 1993, the more than twofold increase in estimated direct medical-care costs attributable to smoking primarily reflect the substantial increase in medical-care expenditures during this period (7). In addition, the 1993 HCFA estimate of national health-care expenditures included expenses not covered by NMES-2 (e.g., hospitalization and other medical-care costs for persons too ill to respond to NMES-2).

This analysis controlled for potential confounders such as sociodemographic status, health insurance status, and risk behaviors other than smoking. Previous estimates assumed the difference in medical-care use between smokers and nonsmokers was primarily attributable to smoking and did not account for other associated risk factors that may result in excessive medical expenditures (4).

The smoking-attributable costs described in this report are underestimated for two reasons. First, the cost estimates do not include all direct medical costs attributable to cigarette smoking (e.g., burn care resulting from cigarette-smoking-related fires, perinatal care for low-birthweight infants of mothers who smoke, and costs associated with diseases caused by exposure to environmental tobacco smoke). Second, the indirect costs of morbidity (e.g., due to work loss and bed-disability days) and loss in productivity resulting from the premature deaths of smokers and former smokers were not included in these estimates. In 1990, estimated indirect losses associated with morbidity and premature mortality were $6.9 billion and $40.3 billion, respectively (3); these estimates suggest that the total economic burden of cigarette smoking is more than twice as high as the direct medical costs described in this report.


  1. CDC. Cigarette smoking among adults -- United States, 1992, and changes in the definition of current cigarette smoking. MMWR 1994;43:342-6.

  2. US Department of Agriculture. Tobacco situation and outlook report. Washington, DC: US Department of Agriculture, Economic Research Service, Commodity Economics Division, June 1994; publication no. TBS-227.

  3. CDC. Cigarette smoking-attributable mortality and years of potential life lost -- United States, 1990. MMWR 1993;42:645-9.

  4. Herdman R, Hewitt M, Laschover M. Smoking-related deaths and financial costs: Office of Technology Assessment Estimates for 1990 -- OTA testimony before the Senate Special Committee on Aging. Washington, DC: US Congress, Office of Technology Assessment Testimony, May 6, 1993.

  5. National Center for Health Services Research and Health Technology Assessment. National Medical Expenditure Survey. Methods II. Questionnaires and data collection methods for the household survey and the Survey of American Indians and Alaska Natives. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, National Center for Health Services Research and Health Technology Assessment, September 1989; DHHS publication no. (PHS)89-3450.

  6. Duan W, Manning WG, Morris CN, Newhouse JP. A comparison of alternative models for the demand for medical care. Journal of Business and Economic Statistics 1983;1:115-26.

  7. Burner ST, Waldo DR, McKusick DR. National health expenditures: projections through 2030. Health Care Financ Rev 1992;14(1).

* Includes hospital-based outpatient and emergency care and care in physicians' offices. 

** In 1993, HCFA excluded all but Medicare- and Medicaid-certified care in this category.

Note: To print large tables and graphs users may have to change their printer settings to landscape and use a small font size.

TABLE 1. Amount * and percentage of total medical-care expenditures attributable to cigarette smoking, by age group and
expenditure category -- United States, 1987 +
                 Physician &      drugs         Hospital     Home-health care @  Nursing-home care       Total
Age             -------------  -------------  -------------  ------------------  -----------------   --------------
  group (yrs)   Amount   (%)   Amount   (%)   Amount   (%)   Amount        (%)   Amount        (%)   Amount    (%)
19-64           $5,185  (8.3)   $224   (1.8)  $ 6,995 (8.2)  $  371       (4.9)    NA **       ---   $12,775  (7.6)
 >=65           $1,439  (5.9)   $303   (3.9)  $ 4,358 (6.6)  $  861       (8.6)  $2,156       (6.6)  $ 9,117  (6.5)

Total           $6,624  (7.7)   $527   (2.6)  $11,353 (7.5)  $1,232       (7.0)  $2,156       (6.6)  $21,892  (7.1)
 * In millions. Based on reported medical-care expenditures of $308.7 billion during 1987.
 + Weighted data.
 & Includes hospital-based outpatient and emergency care and care in physicians' offices.
 @ Includes Medicare- and Medicaid-certified services and other reported services.
** Not applicable.

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Note: To print large tables and graphs users may have to change their printer settings to landscape and use a small font size.

TABLE 2. Amount * and percentage of total medical-care expenditures attributable to cigarette smoking, by age group and
source of payment -- United States, 1987 +
                  Self pay       insurance        Medicare        Medicaid      Other federal    Other state        Other          Total
Age             --------------  --------------  --------------  --------------  ---------------  -------------  -------------   -------------
  group (yrs)   Amount   (%)    Amount   (%)    Amount   (%)    Amount   (%)    Amount    (%)    Amount   (%)   Amount   (%)    Amount   (%)
19-64           $2,274  (17.8)  $6,119  (47.9)  $  728  ( 5.7)  $1,086  ( 8.5)  $1,571   (12.3)   $600   (4.7)   $396   (3.1)   $12,775 (100)
 >=65           $2,325  (25.5)  $1,185  (13.0)  $3,756  (41.2)  $1,158  (12.7)  $  520   ( 5.7)   $ 91   (1.0)   $ 82   (0.9)   $ 9,117 (100)

Total           $4,599  (21.0)  $7,304  (33.4)  $4,485  (20.4)  $2,244  (10.2)  $2,091   ( 9.5)   $692   (3.2)   $478   (2.2)   $21,492 (100)
* In millions.
+ Weighted data.
& Numbers may not add to totals because of rounding.

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