 4. The Social Costs of Smoking in Detail This section describes in more detail the costs of smoking to the community. The major categories of tangible costs are health care, production losses, welfare provision, fires and accidents, pollution and litter, and health research and public health education. Intangible costs consist of loss of life, and pain and suffering. This chapter deals in some detail with the individual categories of smoking costs. It should be noted that we are dealing here with the real costs of smoking, as opposed to the pecuniary costs. The concepts of real and pecuniary costs were discussed in the previous chapter. Pecuniary costs are discussed in more detail in Section 5 below. The broad categories of smoking costs are presented in the following table:
(a) Health Care Medical services Direct medical services are provided for medical conditions resulting directly from tobacco consumption. Co-morbidity medical services are provided for conditions not directly related to smoking but where the consultations or treatments are prolonged, more intensive or more complex because of:
Specific use of prescription drugs results from conditions caused directly by smoking. There may also be more intense use of drugs prescribed for conditions which are not directly tobacco-related but where smoking either makes the drug less effective or necessitates a more extensive or complex drug regimen. Hospital services Hospital bed days may be caused directly by smoking or they may result from co-morbidities. The latter refers to illnesses which are associated with smoking and which cause people to become sicker and to stay in hospital longer when they have been admitted to hospital for other reasons. Other institutional services These are services in other institutions (such as nursing homes and hospices) where admissions are caused by smoking or where smoking has resulted in the condition being more severe, requiring more intensive treatment or causing greater dependency. Allied health services These relate to the use of allied health professionals such as physiotherapists, podiatrists and dietitians for conditions which have been caused or exacerbated by smoking. (b) Production losses Smoking can cause reduced production by an effective reduction in the size of the work force as a result of the deaths or sickness (resulting in absenteeism) of workers. These costs will not be as high if the absent workers can be replaced from otherwise unemployed workers. However, in practice, it is rarely the case that workers can be fully replaced. This is partly because the pool of unemployed workers may be of insufficient size but more likely, in both developed and developing countries, because the skills lost to the work force through smoking may not be replaceable from the ranks of the unemployed. Another significant production cost which must be taken into consideration is reduced on-the-job productivity resulting from smoking-related illnesses. It should be recognised that it is not only in the paid work force that production is lost. There may be substantial production losses among the unpaid work force, for example non-working mothers, the unemployed, the retired and the young. It is true that the output of these people is not counted in conventional national accounts statistics but this is a commentary on the quality of national accounts, not on the contribution to the community of people outside the so-called "working population". If these people die or become sick, either their output is lost or they need to be replaced by other people, who themselves may be drawn from the work force. (c) Welfare provision In communities which provide significant sickness or unemployment welfare benefits there will be some welfare costs resulting from smoking. However, as indicated earlier in Section 3, a significant proportion of these costs will be pecuniary rather than real. To count both production losses and welfare costs for someone suffering from a smoking-related disease would, from the community's point of view, involve double-counting of costs. Welfare costs will always have a budgetary impact but will usually not involve real costs. However, the resources used in administering the welfare system should always be counted as a component of social costs. (d) Fires and accidents Smoking causes fires at home and in workplaces and in some countries is a significant cause of bush and forest fires, as smokers carelessly dispose of cigarette butts. The property losses resulting from these fires represent a significant social cost. Recent evidence suggests that smoking may be a cause of road and other accidents although the mechanisms underlying this relationship do not appear at the moment to be completely clear. (e) Pollution and litter Smoking creates increased pollution and litter as a result of the discarding of packaging and cigarette butts. The resulting costs may be considered to be tangible or intangible. They are tangible if they result in cleaning-up costs. On the other hand, if the litter is allowed to accumulate, rather than being removed, then the costs in terms of a degradation of the environment will be intangible. (f) Research and education In many countries considerable resources are allocated to public health programmes providing education about the harmful effects of smoking, and to health and medical research on smoking. It could be argued that these are discretionary costs resulting from public policy decisions, rather than inevitable costs of smoking. This point is debatable since it is likely that in the absence of these expenditures other types of costs (for example, in the health area) would be higher. Thus there is, at the very least, a strong case for identifying these types of costs. (g) Loss of life There is obviously a value of loss of life to the community over and above the tangible costs of mortality (for example, production losses) borne by the rest of the community. Community attitudes and public policy clearly view premature mortality as highly undesirable. As Peto points out, "For young adults who smoke cigarettes regularly, just over half of those who die in middle age will have been killed by tobacco. Overall, regular cigarette smokers lose about 8 years of non-smoker life expectancy (or 16 years, for the half who are killed by the habit: 20-25 years for those killed in middle age, plus 5-10 years for those killed at older ages."(Peto et al, 1994) A high proportion of smoking-induced deaths occur beyond the age of retirement so that paid production costs become irrelevant. Indeed, an unduly cynical approach would indicate that there are community benefits accruing from these premature deaths because there is no longer the need to provide the consumption resources for these people. The fact that such an attitude would be considered to be outrageous by any civilised community indicates that life has an important psychological value over and above any material contribution which a person may make to the community. To ignore the intangible benefits of life (and so, the intangible costs of premature death) could lead to the totally unacceptable conclusion that smoking, by leading to the premature deaths of retirees, benefits the community as a whole. Evidence that this conclusion would be unreasonable is that most societies devote very considerable proportions of their health resources to extending the lives, and reducing the pain and suffering, of people of above working age. (h) Pain and suffering Similar considerations apply to the smoking-related pain and suffering borne by smokers, passive smokers and others. Although these costs may be difficult to value they cannot be ignored. |