Variation across Canada in the economic burden attributable to excess weight, tobacco smoking and physical inactivity.
Krueger, Hans ; Krueger, Joshua ; Koot, Jacqueline 等
In Canada, tobacco smoking, excess weight and physical inactivity
are among the top five risk factors (RFs) in terms of their attributable
disease burden in the population. (1) The annual economic burden in
Canada ascribed to these three RFs was previously estimated at $50.3
billion in 2012. (2) This previous analysis suggests that even a modest
1% annual relative reduction in the prevalence of tobacco smoking,
excess weight and physical inactivity can have a substantial health and
economic impact over time at the population level, resulting in an
estimated $8.5 billion annual reduction in the economic burden in Canada
by 2031. (2)
The purpose of the current study is twofold: 1) to determine the
potential reduction in economic burden if all provinces achieved
prevalence rates of tobacco smoking, excess weight and physical
inactivity equivalent to those of the province with the lowest rates,
and 2) to update and address a limitation noted in our previous model.
(2)
METHODS
The details of our base model have been previously published. (2,3)
In short, we used an approach based on population attributable fraction
(PAF) to estimate the economic burden associated with the various RFs.
Relative risk
The sources and values for the relative risk (RR) associated with
tobacco smoking, (4) excess weight (5) and physical inactivity (6)
remain the same as in the previously published model.
Risk factor exposure
The analysis of Canada's population exposure to tobacco
smoking, physical inactivity and overweight/obesity used data from the
2012 Canadian Community Health Survey (CCHS). (7) The territories were
not included in our provincial-level analysis, but were included in our
analysis of Canada as a whole. Individuals were considered overweight if
their body mass index (BMI) was between 25 kg/[m.sup.2] and 29.99
kg/[m.sup.2] and obese if their BMI was >30 kg/[m.sup.2], calculated
based on self-reported height and weight. For youth aged 12 to 17 years,
the Cole system of BMI was used to determine overweight and obesity
rates. (8) Tobacco smokers were grouped into light (<10 cigarettes
per day or occasional, non-daily smoking), moderate (10-19 cigarettes
per day) or heavy ([greater than or equal to]20 cigarettes per day)
categories. Physical inactivity rates were based on those individuals
categorized in the CCHS as 'inactive', based on average daily
leisure energy expenditure over the past three months. Respondents were
classified as physically inactive if their leisure energy expenditure
was less than 1.5 kcal/kg/day.
We made one adjustment to this base CCHS data, namely estimating
the rates of overweight, obesity and physical inactivity for children
aged less than 12 years based on the sex-specific rates for 12-14 year
olds in the CCHS. We assumed that children under the age of 12 did not
smoke.
Multiple exposure levels
The PAF of physical inactivity was calculated using the formula PAF
= (E(RR - 1)) / (E(RR - 1) + 1), where E is the proportion of the
population who are physically inactive and RR is the relative risk of
disease developing in the physically inactive group.
Excess weight was regarded as a trichotomous exposure to excess
body weight because three categories of exposure were involved: 1) no
excess weight, 2) overweight (prevalence EOW), and 3) obesity
(prevalence EOB). The PAF calculation used was as follows:
PAF = [E.sub.OW]([RR.sub.OW] - 1) + [E.sub.OB] ([RR.sub.OB] -
1)/[E.sub.OW]([RR.sub.OW] - 1) + [E.sub.OB]([RR.sub.OB] - 1) + 1
Tobacco smoking was regarded as a tetrachotomous exposure because
four categories of exposure were involved: 1) nonsmoking, 2) light
smoking (prevalence ETSL), 3) moderate smoking (prevalence ETSM), and 4)
heavy smoking (prevalence ETSH). The PAF calculation is as follows:
[MATHEMATICAL EXPRESSION NOT REPRODUCIBLE IN ASCII]
Calculating and adjusting costs we estimated the economic burden
(direct and indirect costs) associated with the RFs in each province
using a prevalence-based cost-of-illness approach, and reported this in
2013 Canadian dollars.
Direct costs, including hospital care, physician services, other
health care professionals (but excluding dental services), drugs, health
research, and 'other' health care expenditures were extracted
for each province from the National Health Expenditure Database. (9)
Hospital care, physician care and drug costs by sex were allocated to
each of the co-morbidity categories based on data from the Economic
Burden of Illness in Canada (EBIC) online tool for 2008.10 EBIC cost
data were not sufficiently detailed for a number of co-morbidities,
including ICD-10 codes E11-14, I26, I71, I80-82, K55, K80-82, M45-54. In
each of these situations, we estimated the costs based on the proportion
of sex-specific acute hospital days in 2011/12 for the disease of
interest to the relevant co-morbidity with EBIC 2008 costs. (11)
EBIC 2008 does not allocate costs for other health care
professionals (excluding dental services), health research, or
'other' health care expenditures. These were estimated by
calculating the proportion of total hospital, physician and drug costs
allocated to each co-morbidity by EBIC 2008 and then assuming that this
proportion would be the same for unallocated costs.
These sex-specific direct care costs by co-morbidity were then
multiplied by the calculated risk factor-, sex-, and
co-morbidity-specific PAFs to calculate the direct care costs
attributable to a given risk factor. By completing the analysis at this
level of detail, we are able to segment the results from a number of
perspectives, including an assessment of direct care costs by cost
category, sex, level of risk factor exposure, province and specific
diseases.
Adjusting direct costs in a multifactorial system we then applied
the following formula for calculating the combined PAF in a
multifactorial system to the calculated crude direct costs attributable
to each of tobacco smoking, overweight/ obesity and physical inactivity
(3):
Combined PAF = 1 - [(1 - [PAF.sub.TS])(1 - [PAF.sub.EW])(1 -
[PAF.sub.PIA])]
where [PAF.sub.TS] is the crude PAF of cost for tobacco smoking,
[PAF.sub.EW] is the crude PAF of cost for excess weight and
[PAF.sub.PIA] is the crude PAF of cost for physical inactivity.
A disaggregation step was applied at the end of the direct costing
process to notionally distribute the adjusted economic burden to each RF
according to the proportional distribution of crude costs.
Indirect costs
We calculated indirect costs following the method used in EBIC 1998
(a modified human capital approach *). (12) in order to do so, we
determined the ratio of direct to indirect costs for each diagnostic
category within EBIC 1998, stratified by the specific category of
indirect cost (i.e., short-term disability, long-term disability and
premature mortality). (3) The pertinent ratios (by diagnostic category
and specific indirect cost category) were applied to the previously
identified direct costs within each diagnostic category attributable to
individual RFs in order to generate the equivalent indirect cost data.
Provincial-level analysis
After calculating the adjusted economic burden attributable to the
three RFs in each province, we took the sex- and age-specific prevalence
rates for each RF from the province with the lowest overall prevalence
rate per risk factor and applied those to the populations of each
remaining province. This allowed us to calculate the difference in
annual economic burden for each province based on actual prevalence
rates and those based on the comparator province.
Summary of model updates
As noted in the introduction, a secondary purpose of this study was
to update and address a limitation in our previous model. (2,3) At the
time, we used the most recent data available on resource utilization
from EBiC 199812 and the CiHi Hospital Morbidity Database for 2000/01.
(13) This required the assumption that the distribution of costs had not
significantly changed for specific cost categories over time. Updated
numbers have shown this to be a flawed assumption. The current version
of the model uses 2008 EBIC data, including the distribution of costs by
cost category (hospital care, physician care and drugs), co-morbidity,
sex and province. The allocation of costs by bed-days is used only
occasionally in the model and has been updated to 2011/12 CIHI data.
(11) In addition, the prevalence of risk factors was updated based on
2012 CCHS data (7) (from 2010) and direct costs from the National Health
Expenditure Database were updated to 20139 (from 2012).
RESULTS
The economic burden attributable to excess weight, tobacco smoking
and physical inactivity in Canada in 2013 is $52.8 billion, with $23.3
billion (44.1%) attributable to excess weight, $18.7 billion to tobacco
smoking (35.4%) and $10.8 billion (20.4%) to physical inactivity (see
Table 1).
Overall, the results of the updates to the 2012 model increased the
economic burden attributable to the three RFs from $50.3 billion (in
2012) to $52.8 billion (in 2013), a 4.9% increase (see Table 2).
Updating the model from 1998 to 2008 EBIC data had a negligible
effect on the overall model results, with the annual economic burden in
Canada remaining at $50.3 billion. There was, however, a major shift to
the distribution of the economic burden by risk factor and disease
category (see Table 2). The economic burden attributable to smoking
decreased from $21.3 billion to $18.4 billion (-13.4%). The economic
burden attributable to excess weight and physical inactivity, on the
other hand, increased from $19.0 billion to $21.3 billion (11.7%) and
$10.0 billion to $10.6 billion (6.3%) respectively. The economic burden
attributable to diseases more commonly associated with tobacco smoking
declined substantially as a result of this update (e.g., cancers by
-26.4% and respiratory diseases by -12.6%) while those more commonly
associated with excess weight increased substantially (e.g., diabetes by
+74.0% and musculoskeletal diseases by +15.3%).
Updating the prevalence of risk factors from 2010 to 2012 CCHS data
resulted in a 1.8% increase in the overall economic burden for Canada,
from $50.3 to $51.2 billion (see Table 2). Between 2010 and 2012, the
prevalence of smoking and physical inactivity decreased from 17.9% to
17.5% and 44.3% to 43.6% respectively. The prevalence of overweight
increased from 28.6% to 30.2% while the prevalence of obesity increased
from 14.4% to 16.0%. These changes in risk factor prevalence are
mirrored in the resulting economic burden (see Table 2). That is, the
economic burden attributable to smoking and physical inactivity each
decreased by 1.5%, while the economic burden attributable to obesity
increased by 6.2%.
Finally, updating health care expenditures from 2012 ($205.9
billion in total expenditures) to 2013 ($211.2 billion in total
expenditures) (9) resulted in a 3.1% increase in the annual economic
burden attributable to the three RFs in Canada.
In 2012, the province of British Columbia had the lowest prevalence
of tobacco smoking, excess weight and physical inactivity in Canada. The
prevalence of tobacco smoking ranged from 12.7% in British Columbia to
22.8% in Newfoundland and Labrador (see Figure 1). The prevalence of
excess weight ranged from 43.0% in British Columbia to 59.3% in
Newfoundland and Labrador (see Figure 2). The prevalence of physical
inactivity ranged from 36.1% in British Columbia to 48.5% in Quebec (see
Figure 3). The resulting annual economic burden per capita attributable
to the three RFs in British Columbia in 2013 was lower ($1,249) than any
other Canadian province (ranging from $1,454 in Quebec to $1,932 in
Newfoundland and Labrador) (see Figure 4).
[FIGURE 1 OMITTED]
Applying the sex- and age-specific prevalence rates for each RF
from British Columbia to the population of all other provinces would
result in a reduced annual economic burden per capita ranging between
$130 (in Ontario) and $405 (in Newfoundland and Labrador) (see Figure
5). The total annual reduction in economic burden would range between
$43.2 million in Prince Edward Island to $1,756.8 million in Ontario
(see Figure 6). If all provinces were to achieve BC prevalence rates for
the three risk factors, then $5.3 billion in economic burden could be
avoided annually ($1.7 billion in direct costs and $3.6 billion in
indirect costs). Of this $5.3 billion, $2.8 billion (52.7% of the total
economic burden avoided) would be attributable to a decrease in tobacco
smoking, $1.5 billion (28.0%) to a decrease in physical inactivity and
$1.0 billion (19.4%) to a decrease in excess weight.
[FIGURE 2 OMITTED]
[FIGURE 3 OMITTED]
DISCUSSION
In 2011-2012, the prevalences of excess weight, tobacco smoking and
physical inactivity were lower in BC than in any other Canadian
province. If these age- and sex-specific prevalence rates were achieved
in all other provinces, the annual economic burden attributable to these
three RFs would be reduced by 10.0%. The majority of this reduction
would result from lower smoking rates.
By comparison, our previous analysis suggested that a 1% annual
relative reduction in the three RFs would result in an $8.5 billion
annual reduction in economic burden in Canada by 2031, or 14.3% of the
estimated $59.2 billion (in 2012 constant dollars) total economic burden
that year. (2)
The reasons for lower risk factor rates in BC are complex and
impossible to entirely unravel. For example, BC's culture of
health, together with favourable weather patterns in the southwest of
the province, make outdoor physical activity more possible year-round
than in most other parts of Canada. However, a number of key initiatives
and leaders also have played an important role in helping BC residents
to adopt healthier behaviours. In 2003, BC was awarded the 2010 Winter
Olympics and the government of the day used the opportunity to launch
ActNow BC, "a bold intersectoral initiative that integrates the
actions of the whole-of-government with those of civil society ...
intending to make BC the healthiest jurisdiction to ever host the
Games." (14) The initiative had strong support from the premier of
the province. The BC Healthy Living Alliance (BCHLA), also formed in
2003, released a report titled The Winning Legacy (15) in February of
2005, an evidence-based position paper outlining 27 recommendations to
address the risk factors of excess weight, smoking and physical
inactivity. ActNow BC provided $25.2 million to the BCHLA to pursue
these initiatives. (16) The BC government continues to focus on primary
prevention. (17-19) The province has also benefitted from the visionary
leadership of individuals such as Barbara Kaminsky, the CEO of the
Canadian Cancer Society BC/Yukon Division. She served as the inaugural
leader of the BCHLA and the Primary Prevention Action Group of the
Canadian Partnership against Cancer. More recently, she has spearheaded
the implementation of the Cancer Prevention Centre in BC and is
instrumental in leading its expansion across the country. A report
produced by the Institute for Clinical Evaluative Sciences (ICES) (20)
addressed the question What Does It Take to Make a Healthy Province? and
found that strong political leadership, solutions that can be applied
across governments with the participation of the larger civil society,
timely action even if all evidence is not yet in, and enhanced funding
are all critical.
Although updating our model to include more current data on
resource use and costs had little impact on the overall economic burden
attributable to the three risk factors, the update did produce a
considerable change in the distribution of the economic burden by risk
factor and disease category, resulting in substantially higher costs
attributable to excess weight and lower costs attributable to smoking.
This analysis calls into question our previous assumption that the
distribution of costs have not changed significantly for specific
disease categories over time, suggesting that it is important for data
to be continually updated for this type of economic modelling. A
comparison of acute care days in 2000/01 (13) and 2011/12 (11) similarly
indicates a decrease in the proportion of days treating neoplasms
(-16.3%) and diseases of the circulatory system (-28.3%), and an
increase in the proportion of days treating diseases of the
musculoskeletal system and connective tissue (+9.6%), and endocrine,
nutritional and metabolic diseases (+3.6%). A corresponding shift in
mortality has also been noted globally, with age-standardized death
rates due to cancers, cardiovascular and respiratory diseases declining
between 1990 and 2013 and death rates due to diabetes and
musculoskeletal disorders increasing. (21)
The result of this update also has important policy implications.
From an economic perspective, the impact of excess weight in Canada is
now more substantial than that of tobacco smoking. In addition, the
continuing decline in smoking prevalence between 2010 and 2012, together
with the increasing prevalence of excess weight, resulted in a widened
gap between the economic burdens attributable to these two risk factors.
Our updated model suggests that in 2013, the annual economic burden
attributable to excess weight in Canada was 25% higher than that
attributable to tobacco smoking ($23.3 vs. $18.7 billion). Similar
results have been observed in the United Kingdom, where the economic
burden attributable to excess weight is 65% higher than that
attributable to smoking. (22)
The inclusion of indirect costs in any economic analysis is
controversial, given that a variety of approaches exist, all of which
generate very different results. (23-26) In 1998, EBIC used a modified
human capital approach, changing to the friction cost method ([dagger])
in 2008. The resulting indirect costs vary substantially (see Table 3).
If the friction cost method were applied to the current model, the
indirect economic burden attributable to the three risk factors in
Canada would be reduced from $36.2 to $2.1 billion. The focus of the
friction cost method is on lost production from the "perspective of
firms, consumers and society, without accounting for the potential
income lost on an individual basis," (27) nor does it value
potential time lost due to morbidity or mortality. That is, while
smoking may reduce a person's life by an average of 11-12 years,
(28) the friction cost method only applies a value on the time period
that it takes to replace this individual in the workforce. Placing an
economic value on time lost due to disability and premature mortality
(as in the modified human capital approach) allows us to compare the
broader effect of the risk factors on society as a whole, rather than
from a narrow focus on production losses.
While we have addressed an important limitation in our original
model, other limitations continue to exist. Most importantly, the method
of scaling up from direct to indirect costs depends on the assumption
that the ratios of costs have not changed over time. In addition, the
source for the RRs associated with smoking (4) and physical inactivity
(6) adjust for known confounding factors in generating disease-specific
RRs. The meta-analyses for the RRs associated with overweight and
obesity, however, did not include physical inactivity as a potentially
confounding RF, (5) which may lead to an overestimate of the economic
burden attributable to excess weight. Previous sensitivity analysis also
suggests that the true economic burden may vary by [+ or -]17% of our
best estimate. (2)
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Received: January 15, 2015
Accepted: April 26, 2015
Hans Krueger, PhD, [1,2] Joshua Krueger, BA, [2] Jacqueline Koot,
BSc [2]
Author Affiliations
[1.] School of Population and Public Health, University of British
Columbia, Vancouver, BC
[2.] H. Krueger & Associates Inc., Delta, BC
Correspondence: Hans Krueger, H. Krueger & Associates Inc.,
4554 48B Street,
Delta, BC V4K 2R8, Tel: [telephone]604-946-5464, E-mail:
hans@krueger.ca
Conflict of Interest: None to declare.
* In the human capital approach, gender- and age-specific average
earnings are combined with productivity trends and years of life lost
due to a specific disease/ condition to estimate unrealized lifetime
earnings. An important criticism of this method is that it places a
higher value on the years of life lost for someone with higher earning
potential. In particular, unpaid work and leisure time are not
explicitly accounted for. EBIC 1998 addressed this issue by explicitly
valuing nonproductive time.
([dagger]) The friction cost method attempts to measure only actual
production losses to society during the friction period between the
start of an absence from work (resulting from short-term absence,
long-term absence, disability and mortality) and when original
productivity levels are restored.
Table 1. Estimated prevalence of RFs, total economic burden for
multifactorial system, and disaggregated costs by RF, Canada, 2013,
by sex adjusted for multiple RFs in one individual
% #
Population Individuals
with RF with RF
Males
Smokers
Light 7.7% 1,321,342
Moderate 5.8% 1,005,588
Heavy 6.4% 1,105,548
Subtotal--Male smokers 19.9% 3,432,478
Excess weight
Over weight 36.7% 6,326,997
Obese 16.1% 2,776,253
Subtotal--Male excess weight 52.9% 9,103,250
Inactive 40.8% 7,030,810
Subtotal
Females
Smokers
Light 7.6% 1,323,306
Moderate 4.8% 848,665
Heavy 2.8% 484,763
Subtotal--Female smokers 15.2% 2,656,735
Excess weight
Over weight 23.7% 4,155,943
Obesity 15.8% 2,776,253
Subtotal--Female excess weight 39.6% 6,932,196
Inactive 46.3% 8,109,515
Subtotal
Both sexes
Smokers
Light 7.6% 2,644,648
Moderate 5.3% 1,854,254
Heavy 4.6% 1,590,311
Subtotal--Smokers 17.5% 6,089,212
Excess weight
Over weight 30.2% 10,482,940
Obesity 16.0% 5,552,506
Subtotal--Excess weight 46.1% 16,035,446
Inactive 43.6% 15,140,325
Total
Direct cost Indirect
per individual cost per
with RF ($) individual
with RF ($)
Males
Smokers
Light $769 $1,497
Moderate $1,274 $2,456
Heavy $1,559 $2,984
Subtotal--Male smokers $1,171 $2,257
Excess weight
Over weight $199 $554
Obese $722 $1,645
Subtotal--Male excess weight $358 $887
Inactive $238 $497
Subtotal
Females
Smokers
Light $570 $1,103
Moderate $994 $1,936
Heavy $1,563 $3,045
Subtotal--Female smokers $887 $1,723
Excess weight
Over weight $291 $753
Obesity $867 $1,879
Subtotal--Female excess weight $521 $1,204
Inactive $197 $495
Subtotal
Both sexes
Smokers
Light $669 $1,300
Moderate $1,146 $2,218
Heavy $1,560 $3,003
Subtotal--Smokers $1,047 $2,024
Excess weight
Over weight $235 $633
Obesity $794 $1,762
Subtotal--Excess weight $429 $1,024
Inactive $216 $496
Total
Total cost per Total direct
individual cost of RF
with RF ($) (million$)
Males
Smokers
Light $2,266 $1,016
Moderate $3,730 $1,281
Heavy $4,543 $1,723
Subtotal--Male smokers $3,428 $4,020
Excess weight
Over weight $753 $1,258
Obese $2,367 $2,003
Subtotal--Male excess weight $1,245 $3,261
Inactive $735 $1,673
Subtotal $8,955
Females
Smokers
Light $1,673 $755
Moderate $2,930 $844
Heavy $4,608 $757
Subtotal--Female smokers $2,610 $2,356
Excess weight
Over weight $1,044 $1,209
Obesity $2,746 $2,406
Subtotal--Female excess weight $1,725 $3,615
Inactive $692 $1,600
Subtotal $7,571
Both sexes
Smokers
Light $1,969 $1,771
Moderate $3,364 $2,125
Heavy $4,563 $2,481
Subtotal--Smokers $3,071 $6,376
Excess weight
Over weight $868 $2,467
Obesity $2,556 $4,409
Subtotal--Excess weight $1,453 $6,876
Inactive $712 $3,273
Total $16,526
Total Total cost
indirect of RF
cost of RF (million$)
(million$)
Males
Smokers
Light $1,978 $2,994
Moderate $2,469 $3,751
Heavy $3,299 $5,023
Subtotal--Male smokers $7,747 $11,767
Excess weight
Over weight $3,505 $4,763
Obese $4,567 $6,571
Subtotal--Male excess weight $8,072 $11,334
Inactive $3,493 $5,166
Subtotal $19,312 $28,267
Females
Smokers
Light $1,460 $2,214
Moderate $1,643 $2,487
Heavy $1,476 $2,234
Subtotal--Female smokers $4,579 $6,935
Excess weight
Over weight $3,128 $4,337
Obesity $5,216 $7,623
Subtotal--Female excess weight $8,345 $11,960
Inactive $4,012 $5,612
Subtotal $16,936 $24,506
Both sexes
Smokers
Light $3,438 $5,208
Moderate $4,112 $6,237
Heavy $4,775 $7,256
Subtotal--Smokers $12,325 $18,702
Excess weight
Over weight $6,633 $9,100
Obesity $9,784 $14,193
Subtotal--Excess weight $16,417 $23,293
Inactive $7,505 $10,778
Total $36,248 $52,773
RF = Risk factor.
Table 2. Summary effect of updating the 2012 model for
Canada, changes by risk factor and disease category
Update
2012 Model EBIC
(millions) (million$) % Change
By risk factor
Smokers
Light $5,906 $5,095 -13.7%
Moderate $7,048 $6,120 -13.2%
Heavy $8,334 $7,221 -13.4%
Subtotal--Smokers $21,288 $18,435 -13.4%
Excess weight
Over weight $7,522 $8,523 13.3%
Obesity $11,515 $12,739 10.6%
Subtotal--Excess weight $19,037 $21,262 11.7%
Inactive $9,988 $10,619 6.3%
Total $50,313 $50,316 0.0%
By disease category
Cardiovascular diseases $21,027 $20,665 -1.7%
Cancers $9,783 $7,202 -26.4%
Musculoskeletal diseases $9,291 $10,713 15.3%
Respiratory Diseases $6,634 $5,800 -12.6%
Diabetes $3,222 $5,606 74.0%
Other $354 $330 -6.9%
Total $50,313 $50,316 0.0%
2012 CCHS 2013 Costs
(million$) % Change (million$)
By risk factor
Smokers
Light $5,059 -0.7% $5,208
Moderate $6,058 -1.0% $6,237
Heavy $7,048 -2.4% $7,256
Subtotal--Smokers $18,165 -1.5% $18,702
Excess weight
Over weight $8,825 3.5% $9,100
Obesity $13,759 8.0% $14,193
Subtotal--Excess weight $22,584 6.2% $23,293
Inactive $10,454 -1.5% $10,778
Total $51,204 1.8% $52,773
By disease category
Cardiovascular diseases $21,005 1.6% $21,656
Cancers $7,236 0.5% $7,445
Musculoskeletal diseases $11,120 3.8% $11,462
Respiratory Diseases $5,799 0.0% $5,971
Diabetes $5,691 1.5% $5,877
Other $352 6.5% $362
Total $51,204 1.8% $52,773
% Change
2012 to
% Change 2013 Model
By risk factor
Smokers
Light 2.9% -11.8%
Moderate 3.0% -11.5%
Heavy 3.0% -12.9%
Subtotal--Smokers 3.0% -12.1%
Excess weight
Over weight 3.1% 21.0%
Obesity 3.2% 23.3%
Subtotal--Excess weight 3.1% 22.4%
Inactive 3.1% 7.9%
Total 3.1% 4.9%
By disease category
Cardiovascular diseases 3.1% 3.0%
Cancers 2.9% -23.9%
Musculoskeletal diseases 3.1% 23.4%
Respiratory Diseases 3.0% -10.0%
Diabetes 3.3% 82.4%
Other 3.0% 2.1%
Total 3.1% 4.9%
Update EBIC = EBIC 2008 (including EBIC cost distribution) updated from
EBIC 1998 (cost distribution based on patient bed-days).
2012 CCHS = 2012 CCHS prevalence data updated from 2010 CCHS.
2013 Costs = 2013 CIHI NHEX expenditures updated from 2012 CIHI NHEX.
Table 3. Economic burden of illness in Canada by diagnostic
category, indirect costs as percent of direct costs
EBIC 1998 (Human capital)
Diagnostic
category Mortality Morbidity Total
Malignant and 431% 46% 478%
other neoplasms
Endocrine, 64% 55% 119%
nutritional and
metabolic
diseases
Cardiovascular 121% 50% 171%
diseases
Respiratory 48% 99% 146%
diseases/
infections
Digestive 32% 33% 65%
diseases
Musculoskeletal 5% 514% 519%
diseases
EBIC 2008 (Friction)
Diagnostic
category Mortality Morbidity Total
Malignant and 3.5% 8.8% 12.3%
other neoplasms
Endocrine, 0.4% 2.5% 2.9%
nutritional and
metabolic
diseases
Cardiovascular 0.8% 2.3% 3.1%
diseases
Respiratory 0.3% 46.8% 47.1%
diseases/
infections
Digestive 0.4% 2.7% 3.2%
diseases
Musculoskeletal 0.0% 24.1% 24.2%
diseases
Figure 4. Annual economic burden per capita in Canada ($)
attributable to tobacco smoking, excess weight and
physical inactivity, by province and direct/indirect
costs, 2013
Annual Economic Burden Per Capita
Province
BC AB SK MB ON
Indirect ($) 843.86 1056.44 1254.77 1126.14 1016.56
Direct ($) 404.92 486.47 575.12 529.60 450.10
Province
QC NB NS PEI NL
Indirect ($) 998.30 1307.98 1256.85 1275.16 1300.43
Direct ($) 455.94 613.61 587.40 577.15 631.50
Figure 5. Changes in annual per capita economic burden in
Canada ($) based on BC risk factor prevalence, by
province and direct/indirect costs, 2013
Changes in Province
Annual Per
Capita Economic
Burden BC AB SK MB ON
Indirect ($) 0.00 -104.29 -220.11 -124.51 -88.72
Direct ($) 0.00 -51.11 -100.57 -59.98 -40.93
Changes in Province
Annual Per
Capita Economic
Burden QC NB NS PEI NL
Indirect ($) -122.54 -241.65 -189.81 -202.65 -271.2
Direct ($) -59.51 -116.46 -91.72 -94.27 -133.5
Figure 6. Changes in annual economic burden in Canada
(million$) based on BC risk factor prevalence, by
province and direct/indirect costs, 2013
Changes in
Annual
Economic
Burden
($Millions) Province
' BC AB SK MB ON
Indirect 0.00 -417.90 -243.50 -157.56 -1202.18
($ Millions)
Direct 0.00 -204.79 -111.25 -75.89 -554.61
Changes in
Annual
Economic
Burden
($Millions) Province
' QC NB NS PEI NL
Indirect -999.18 -182.60 -178.98 -29.49 -143.29
($ Millions)
Direct -485.24 -88.00 -86.49 -13.72 -70.53
($ Millions)
