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Costs of Smoking Among Active Duty U.S. Air Force Personnel --- United States, 1997

Smoking is the leading cause of preventable disease and death in the United States (1). The health consequences of smoking impose a substantial economic toll on persons, employers, and society. Smoking accounts for $50--$73 billion in annual medical-care expenditures, or 6%--12% of all U.S. medical costs (2--5). The costs associated with lost productivity also are extensive (2). In 1997, approximately 25% of male and 27% of female active duty Air Force (ADAF) personnel aged 17--64 years were smokers (6). A 1997 retrospective cohort study was conducted among ADAF personnel to estimate the short-term medical and lost productivity costs of current smoking to the U.S. Air Force (USAF). This report summarizes the results of the study, which indicate that current smoking costs the USAF approximately $107.2 million per year: $20 million from medical-care expenditures and $87 million from lost workdays.

Study participants completed a health assessment survey and were followed for 1 year; then researchers calculated participants' use of medical care and health-related lost work time (i.e., time spent on smoke breaks, days spent in the hospital, and time away from duty station for outpatient clinic visits). Total expenditures among current smokers and never smokers were used to compute population-attributable fractions (PAFs) (i.e., the fraction of expenditures attributable to ADAF members who currently smoked). Data were collected from 5164 active duty TRICARE Prime enrollees aged 17--64 years in Arkansas, Louisiana, Oklahoma, and Texas who completed the Health Enrollment Assessment Review (HEAR) survey during September--December 1996, and who remained enrolled in the health plan the year following the HEAR survey. The HEAR instrument is a voluntary survey given to all TRICARE Prime enrollees. Self-reported demographic data were obtained by written questionnaires from the Air Force personnel system; smoking status, weekly alcohol consumption, frequency of aerobic exercise, and body mass index data also were obtained through self-administered questionnaires from HEAR (Table 1) (7). Respondents were classified as current, former, or never smokers*. Results for former smokers were not included in this study. Inpatient and outpatient visits, clinical diagnoses, bed days, and encounter costs were obtained from the Corporate Executive Information System (CEIS) and the TRICARE Management Activity. Prevalence estimates of all currently smoking ADAF personnel during 1997 were based on a linear interpolation of results from the 1995 and 1998 U.S. Department of Defense (DoD) Survey of Health Related Behaviors Among Military Personnel (6--8). Prevalence estimates in the DoD survey were 22% and 49% higher than HEAR among men and women, respectively. The DoD survey of risk behaviors is anonymous and is assumed to reflect current smoking in the ADAF population more accurately than the HEAR survey, which is not anonymous.

An empirical model was used to compare medical-care expenditures and lost work time among current smokers and never smokers. Men and women were modeled separately because of the influence of pregnancy-related events. A log-linear Poisson regression model was used to compare the rates of accumulating medical-care costs. Sex-specific rate ratios (RRs) were adjusted for age, race, weekly alcohol consumption, frequency of aerobic exercise, and body mass index. Adjusted RRs from HEAR were combined with current smoking prevalence data from the DoD survey to estimate PAFs of expenditures associated with current smoking for all ADAF personnel. The use of two distinct datasets in the PAF formula precluded computing confidence intervals (CIs). The average margin of error (one half the width of the CI around the mean) was ±3.6% for the RR estimates and ±4.1% for the prevalence estimates. The RR margins of error and smoking prevalence estimates indicate the overall stability of the PAFs. Smoking-attributable expenditures (SAEs) among men and women were calculated by multiplying the PAFs by total medical-care costs for each sex. Total medical-care costs for all ADAF personnel were $347 million and were estimated by using CEIS data to extrapolate the sex-specific medical-care costs for the study cohort to the entire ADAF population. Productivity costs were estimated using 1996 age-specific and sex-specific salary and benefit data among ADAF personnel. Hospital days, outpatient clinic visit time, and excess break time for current smokers were included; nonhospital sick days were excluded.

Smoking-attributable medical-care costs for ADAF personnel were approximately $20 million (Table 1), representing approximately 6% of the total annual Air Force medical system expenditures. In 1997, current smoking was associated with 893,128 lost workdays: 739,374 among men and 153,755 among women. Assuming 250 workdays per year, this lost work time represents a loss of approximately 3573 full-time equivalent positions (FTEs) in 1997: 2957 among men and 615 among women. Lost workdays represent approximately $87 million in annual productivity losses: $76 million among men and $11 million among women.

Reported by: AS Robbins, MD, SY Chao, MS, GA Coil, MPH, VP Fonseca, MD, Office for Prevention and Health Svcs Assessment, Air Force Medical Operations Agency, Brooks Air Force Base, Texas. Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note:

Current smoking among ADAF personnel is associated with large medical expenditures and lost productivity each year, particularly among men. The 6% SAF of medical expenditures is within the 6%--12% range of recent SAF estimates of total U.S. medical costs (2--5). DoD estimated that current smoking among all U.S. military health system beneficiaries cost the DoD an estimated $930 million in 1995: $584 million in annual health care expenditures and $346 million in lost productivity (9). Among ADAF personnel, smoking-attributable productivity losses were more than four times the cost of medical care: 6.7 times among women and 4.1 times among men. The number of lost FTEs is larger than the number of FTEs on active duty at 35 (40%) of 87 USAF installations.

The findings in this report differ from previous cost-of-smoking estimates because the study population in this report excludes persons aged >65 years; the costs for former smokers were excluded. Consequently, medical costs among this younger population are a much smaller percentage of total smoking-attributable costs than in other studies (2,3). The exclusion of results for former smokers also lowers the costs of smoking estimates for women compared with men. Pregnancy-related events were a large portion of health-care use among ADAF women. Because a substantial proportion of women quit smoking during pregnancy and many others conceal their smoking status during pregnancy (10), the SAEs PAFs among women who are classified as current smokers may be artificially low; this may account for the lower costs of smoking for women relative to men. In 1993, smoking-attributable medical costs for the United States were approximately 51% lower for women than men (4).

The findings in this report are subject to at least four limitations. First, the study cohort may not be representative of all ADAF personnel. Second, study participants knew their HEAR survey responses would become part of their medical record. This might have reduced the rate of self-reported smoking and other risk behaviors when compared with anonymous ADAF surveys (6--8); however, anonymity may be only one factor influencing differences in reported risk behaviors. Third, the medical-care costs and productivity losses of former smokers were not included. Finally, the study excluded lost productivity on days that ADAF personnel were on convalescent leave or confined to quarters; a large number of work days may have been missed because of less severe illnesses that did not require hospitalization. Limitations two, three, and four may underestimate the costs of smoking among ADAF personnel.

These results support USAF and DoD efforts to decrease the prevalence of smoking among ADAF personnel. Smoking-attributable lost work time is particularly important for USAF operational commanders because it adversely affects military readiness; however, the impact of smoking on productivity also is relevant to civilian employers. The prevalence of smoking among ADAF members is approximately the same as among the U.S. population aged 18--64 years (1). However, because of physical training requirements, smokers in the ADAF population are probably healthier than smokers in the civilian population. If so, average productivity losses to civilian employers could be larger than those found in this military group. Costs related to tobacco use are largely preventable. Implementing comprehensive tobacco-control programs remains an effective way to reduce associated medical and productivity losses.


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  6. Bray RM, Sanchez RP, Ornstein ML, et al. 1998 Department of Defense Survey of Health Related Behaviors Among Military Personnel. Research Triangle Park, North Carolina: Research Triangle Institute, 1999.
  7. US Air Force Office for Prevention and Health Services Assessment. Health Enrollment Assessment Review 1.0 (HEAR) High Resource Utilization (HRU) Validation Study: final report. Washington, DC: Report for the Air Force Medical Operations Agency, January 1999.
  8. Bray RM, Kroutil LA, Wheeless SC, et al. 1995 Department of Defense Survey of Health Related Behaviors Among Military Personnel. Research Triangle Park, North Carolina: Research Triangle Institute, 1995.
  9. Helyer AJ, Brehm WT, Perino L. Economic consequences of tobacco use for the Department of Defense, 1995. Mil Med 1998;163:217--21.
  10. Kendrick JS, Zahniser SC, Miller N, et al. Integrating smoking cessation into routine public prenatal care: the smoking cessation in pregnancy project. Am J Public Health 1995;85:217--22.

* HEAR defined current smokers as those who, at the time of the interview, smoked cigarettes every day or some days, and former smokers as those who currently did not smoke but had smoked in the past.

The DoD survey defined current smokers as those who had smoked >100 cigarettes during their lifetime and smoked within the 30 days preceding the survey, former smokers as those who had smoked >100 cigarettes during their lifetime but had not smoked within the 30 days preceding the survey, and never smokers as those who had smoked <100 cigarettes during their lifetime.

Table 1

Table 1
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