The economic benefits of risk factor reduction in Canada: tobacco smoking, excess weight and physical inactivity.

Krueger, Hans ; Turner, Donna ; Krueger, Joshua 等

Despite years of successful reduction in the prevalence of tobacco smoking, (1,2) it remains the number one risk factor (RF) with respect to the preventable disease burden in Canada and the United States. (3,4) Recent trend information from the US suggests a convergence of relative and absolute risk of death from smoking in men and women, resulting from the convergence of smoking patterns between the sexes since the 1960s. (5) Furthermore, the rate of death from chronic obstructive pulmonary disease (COPD) appears to be increasing in both male and female smokers, possibly due to design changes in cigarettes that promote deeper inhalation of smoke. (5)

Excess weight is second on the list of RFs with respect to the preventable disease burden in Canada and the US, (3) and yet this RF continues to increase in prevalence. (6) Both excess weight and physical inactivity have independently been implicated as RFs for a variety of chronic diseases. Consequently, these RFs have joined tobacco smoking as key prevention targets.

Estimations of the economic burden generated by such RFs have been undertaken in many jurisdictions in the world, (7) including Canada (8-12) and several Canadian provinces. (13,14) In addition to understanding the costs related to a single RF, estimating the aggregate economic burden generated by two or more RFs in a population is often of interest. (15) This information can inform prevention strategies aimed at more than one RF. There are, however, analytical challenges involved with the estimation of the aggregate burden of multiple RFs in a population. Certain costs (e.g., those generated by incident disease or death) are, by definition, accrued only once. Thus, it is important to account for the confounding effect of multiple RFs in the same individual, and specifically to adjust for any increase in the calculated economic burden due to double counting cases and costs. (16)

The purpose of this study is twofold: 1) to apply a recently developed approach to address this issue of double counting in estimating the combined economic burden of tobacco smoking, excess weight and physical inactivity in Canada, and 2) to estimate the economic benefits of long-term RF reduction in Canada. (16) This current model has been updated to include economic data for the year 2012, prevalence and relative risk information for tobacco smoking by intensity and a flexible module, which can be used to estimate the economic benefits of long-term RF reduction.

METHODS

The details of our base model have been previously published. (16) In short, we used an approach based on population attributable fraction (PAF) to estimate the economic burden associated with the various RFs. PAF is a statistic that combines two facets of a RF and its impact on disease: relative risk (RR) of the RF in reference to a particular disease, and the prevalence of exposure to the RF in the population of interest.

[FIGURE 1 OMITTED]

Relative risk

The sources for the RRs associated with excess weight and physical inactivity remain the same as in the previously published model. (9,17) The 2013 study on 1.3 million UK women was used as the source for RR data associated with tobacco smoking. (2) RRs were adjusted for geographic region, age, body mass index (BMI), socio-economic status, current alcohol intake, weekly strenuous physical activity, height, oral contraceptive use, menopausal status and menopausal hormone therapy use. RRs are also presented by three levels of smoking intensity based on the number of cigarettes smoked per day at the time of study recruitment, namely <10, 10-19 or [greater than or equal to] 20.

The relative risk data for excess weight is specific to males and females while the source of RR data for physical inactivity did not make this distinction. An additional review of research for sex variations associated with physical inactivity and the risk of stroke, (18) colon (19) and rectal cancers, (20) supported the assumption that there is no significant difference in RR between males and females for this RF. The source of RR data for tobacco smoking is based on females only. Recent information suggests a convergence in RR between females and males, especially when adjusted for smoking intensity. (5) Even without adjusting for smoking intensity, Jha and colleagues found no significant differences between the sexes in adjusted hazard ratios for various causes of death in current smokers, including cancers, vascular diseases, respiratory diseases and all causes. (1) We therefore assumed that the RRs by smoking intensity would be the same for males and females by disease category.

The point estimates of the RRs are used for calculations in the base model with the upper and lower bounds of the 95% confidence intervals assessed in a sensitivity analysis.

Risk factor exposure

The other half of a PAF calculation depends on high-quality RF prevalence data. (21) The analysis of Canada's population exposure to tobacco smoking, physical inactivity and overweight/obesity began with information drawn from the 2010 Canadian Community Health Survey (CCHS). First, overweight and obese individuals were those with a BMI of between 25 kg/[m.sup.2] and 30 kg/[m.sup.2] for overweight and 30 kg/[m.sup.2] or greater for obesity, calculated based on self-reported height and weight. For youth aged 12 to 17, the Cole system of BMI was used to determine overweight and obesity rates. (22) Second, tobacco smokers were grouped into light (<10 cigarettes per day), moderate (10-19 per day) and heavy ([greater than or equal to] 20 per day) smokers based on additional details on the average number of cigarettes smoked per day. (23) All current smokers who identified themselves as occasional smokers were included in the "light" smoking category. Third, physically inactive individuals were those categorized in the CCHS as "inactive."

We made one adjustment to these 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 no smoking occurs in children younger than 12 years of age.

Multiple exposure levels

The most basic version of a PAF calculation, derived from the prevalence of a single RF and the RR of a related disease, uses the formula (E(RR-1)) / (E(RR-1)+ 1)), where E is the proportion of the population exposed to the factor of interest and RR is the relative risk of disease developing in the group exposed to the factor.

More sophisticated approaches are required to calculate PAF when a polytomous RF is involved. (24) This is the case for both the excess weight and the tobacco smoking RFs in the current model. Overweight and obesity should be conceived as a trichotomous exposure to excess body weight; i.e., 1) no excess weight, 2) intermediate excess or overweight (prevalence [E.sub.OW]), and 3) more extreme excess or obesity (prevalence [E.sub.OB]). The PAF calculation is as follows:

([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, on the other hand, should be conceived as a tetrachotomous exposure; i.e., 1) non-smoker, 2) light smoker (prevalence [E.sub.TSL]), 3) moderate smoker (prevalence [E.sub.TSM]), and 4) heavy smoker (prevalence [E.sub.TSH]). The PAF calculation is as follows:

([E.sub.TSL]([RR.sub.TSL]-1) + [E.sub.TSM]([RR.sub.TSM]-1) + [E.sub.TSH]([RR.sub.TSH]-1)) / ([E.sub.TSL]([RR.sub.TSL]-1) + [E.sub.TSM]([RR.sub.TSM]-1) + [E.sub.TSH]([RR.sub.TSH]-1) + 1))

Calculating and adjusting costs

We estimated the economic burden using a prevalence-based cost-of-illness approach, and reported this in 2012 Canadian dollars. We began calculating direct costs using the approach adopted by Anis et al. (11) In short, 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 from the National Health Expenditure Database for Canada. (25) All costs (except hospital care) were allocated to each of the co-morbidity categories based on weights published in the Economic Burden of Illness in Canada (EBIC) for 1998. (26) Hospital costs were allocated to each co-morbidity based on the proportion of total patient bed-days (based on data from the Canadian Institute for Health Information (CIHI) Hospital Morbidity Database 2000/2001) (27) used in treating patients in Canada with that co-morbidity. Estimated total direct costs were distributed between males and females based on the proportion of hospital bed-days in 2000/2001 utilized by males and females for each of the co-morbidities. Finally, the Canadian sex-specific costs by co-morbidity were multiplied by the calculated sex- and comorbidity-specific PAF. We calculated indirect costs (premature mortality, short- and long-term disability) following the method used in EBIC, 1998 (a modified human-capital approach).

Economic benefits of risk factor reduction

A number of key assumptions were made in modelling the economic benefits associated with future RF reduction in the Canadian population. First, population projections for the 20-year timeframe from 2012 to 2031 by sex and five-year age group were based on projections by Statistics Canada. (28) Second, RF prevalence by sex and five-year age group was calculated for 2010 using the CCHS 2010 Public Use Microdata File. (23) Third, the base model uses a constant 1% relative annual reduction in the RFs of tobacco smoking, physical inactivity and excess weight. Current trends of decreasing smoking prevalence and increasing weight and inactivity are not factored into the model. Fourth, constant 2012 dollars are used throughout the modelling process (i.e., no adjustments are made for projected inflation) in order to clearly identify changes in the economic burden associated with changing RF prevalence, rather than confusing these results with inflationary increases. Fifth, obese individuals move into the overweight category while overweight individuals move into the healthy weight category. Sixth, the benefits associated with physical activity and moving to a healthier weight accrue within a year. (29) Last, the benefits of smoking cessation accrue over time, as per Figure 1. (30)

RESULTS

Table 1 shows the fully adjusted prevalence of RF exposure, the statistically significant RR data by sex and the calculated PAF of disease incidence related to each RF. The PAF for all co-morbidities, with the obvious exception of gynecological and breast cancers, vary by sex. This type of detailed analysis has important implications in determining direct and indirect costs.

Table 2 includes a summary of the adjusted estimates of the prevalence of the chronic disease RFs, the absolute numbers of Canadians with each RF and the fully adjusted economic results. The total annual economic burden in Canada attributable to these RFs is $50.3 billion ($15.4/$34.9 billion in direct/indirect costs).

Figure 2 represents the RF-specific burden graphically, with additional information on the components that constitute the indirect costs. The indirect burden related to premature mortality dominates as an outcome of tobacco smoking ($9.7 billion, or 68% of $14.3 billion in total indirect costs for that RF) and is also marginally higher than disability in the case of physical inactivity. The reverse is true for excess weight, where the economic burden of disability ($8.1 billion) outstrips the costs of premature mortality ($5.5 billion).

This analysis indicates that the disaggregated economic burden for excess weight in Canada in 2012 at $19.0 billion remains lower than the economic burden related to tobacco smoking at $21.3 billion.

It appears that cardiovascular diseases tend to dominate the disease burden that is attributable to these RFs. Of the $50.3 billion in annual economic burden, $21.0 billion (41.8%) is associated with cardiovascular diseases, $9.8 billion (19.4%) with cancers, $9.3 billion (18.5%) with musculoskeletal diseases, $6.6 billion (13.2%) with respiratory diseases and $3.2 billion (6.4%) with diabetes (see Figure 3).

Table 3 provides a summary of the estimated number of individuals in Canada with the RFs in 2012 and compares them to 2031 with either an assumption of no change or a 1% relative annual reduction in RF prevalence. With a 1% reduction, the proportion of Canadians who smoke would decrease from 17.9% in 2012 to 13.6% in 2031. In terms of absolute numbers of Canadians who smoke, the decrease would be from 6.2 million in 2012 to 5.7 million in 2031. The proportion of Canadians with excess weight would decrease from 42.9% to 38.7% while the proportion of physically inactive Canadians would decrease from 44.3% to 37.5%.

The economic burden associated with these RFs in Canada would increase from $50.3 billion in 2012 to $59.2 billion in 2031 (in constant 2012 dollars), assuming no change in RF prevalence, i.e., based solely on population growth (see Table 4). A 1% relative annual reduction in each of the three RFs would result in this projected economic burden of $59.2 billion decreasing to $50.8 billion (-$8.5 billion) in 2031. This reduction consists of $3.2, $3.1 and $2.1 billion, respectively, for decreases in excess weight, tobacco smoking and physical inactivity (see Figure 4). Over the 20-year period from 2012 to 2031, a 1% relative annual reduction in these RFs would result in an estimated cumulative reduction in economic burden of $78.0 billion (consisting of $31.2, $26.4 and $20.3 billion, respectively, for decreases in excess weight, tobacco smoking and physical inactivity).

Sensitivity analysis

The point estimates for RR are used in the base model results presented above. We used the lower and upper bounds of the 95% CI for the RR associated with each RF and disease in a sensitivity analysis. Using the lower bounds resulted in a decrease in the total estimated economic burden in 2012 from $50.3 billion to $41.6 billion (or -17.3%) while applying the upper bounds increased the total economic burden to $58.7 billion in 2012 (or +16.7%) (see Table 5).

DISCUSSION

The annual economic burden of the RFs of tobacco smoking, excess weight and physical inactivity in Canada are estimated at $50.3 billion in 2012 ($15.4/$34.9 billion in direct/indirect costs). Of this amount, $21.3 billion is attributable to tobacco smoking ($7.0/$14.3 billion in direct/indirect costs), $19.0 billion is attributable to excess weight ($5.4/$13.6 billion in direct/indirect costs), and $10.0 billion is attributable to physical inactivity ($3.0/$7.0 billion in direct/indirect costs).

Total health care expenditures in Canada in 2012 are estimated at $207.4 billion. (25) The total direct health care costs attributable to tobacco smoking, excess weight and physical inactivity of $15.4 billion represents 7.4% of this total. Kaiserman estimated smoking attributable health care costs in Canada in 1991 to be $2.5 billion, (12) or about 3.8% of the $66.3 billion total health care costs in Canada that year. (25) Similarly, Rehm and colleagues estimated smoking attributable health care costs in Canada in 2002 to be $4.4 billion, (31) or 3.8% of the $115.1 billion total health care costs in Canada that year. (25) Our finding of 3.4% ($7.0 of $207.4 billion) may be at least partially attributable to a reduction in smoking prevalence from 25.9% to 19.9% of the population aged 12 and over in Canada during the last decade (32) as well as adjustments made to avoid double counting. Katzmarzyck and Janssen estimated the direct health care costs attributable to physical inactivity and obesity to be $1.6 billion each in 2001, (9) or 1.5% of the $107.2 billion total health care costs in Canada that year. (25) Our estimate of 2.6% for excess weight includes both overweight and obesity. Including just obesity would reduce direct care costs to 1.7% ($3.5 of $207.4 billion), or slightly higher than the 1.5% estimated by Katzmarzyck and Janssen. Anis and colleagues estimated the combined direct costs of overweight and obesity in Canada in 2006 to be $6.0 billion, or 4.0% of the $150.8 billion total health care costs in Canada that year. (25) Of the $6.0 billion, approximately $4.0 billion (or 2.6% of $150.8 billion) is attributable to obesity. Our estimate of 1.4% ($3.0 billion of $207.4 billion) attributable to physical inactivity is somewhat lower than previous estimates of 1.5%. (9) Lower estimates of the direct costs attributable to tobacco smoking, excess weight and physical inactivity observed in the current study compared with previous Canadian studies may be at least partially due to addressing double counting when assessing the economic impact of multiple RFs within the population. In addressing double counting, the aggregate economic burden was 13.4% lower than the total that would be generated by crude summation of costs generated by each of the three RFs.

Another important result, generated by having access to sex-specific RF prevalence and RR data, is the difference between males and females in contributing to the total economic burden. Of the $50.3 billion, $26.5 billion (52.8%) is attributable to males and $23.8 billion to females. The costs associated with tobacco smoking, however, are higher for males ($13.0 billion) than for females ($8.3 billion), which is a reflection of the continuing higher prevalence of tobacco smoking among men (20.7% vs. 15.0% among women) and the fact that a higher proportion of men are heavy smokers (6.5% vs. 3.0%). The overall sex-specific distribution for the burden of key modifiable RFs has important implications for prevention planning and public health messaging.

[FIGURE 4 OMITTED]

Our analysis suggests that even a modest 1% annual relative reduction in the RFs of tobacco smoking, excess weight and physical inactivity can have a substantial health and economic impact over time at the population level. Indeed, such a change could bend the cost curve over a 20-year period to the point where the economic burden associated with these RFs would remain essentially constant despite the projected growth in Canada's population from 33 million in 2012 to 42 million in 2031.

The analysis of the economic burden related to the RF system and the individual RFs is the first phase of any attempt to project the potential economic impact of applying known primary prevention initiatives. A key question is whether a 1% annual relative reduction in these RFs, as assumed in the current analysis, is achievable over the long term. Between 2001 and 2011, smoking rates in Canada fell from 25.9% to 19.9% for the population aged 12 and over (32) (a 2.6% relative annual reduction). There are also a number of promising approaches worldwide which include addressing the RFs of excess weight and physical inactivity, (33) such as the experience in North Karelia, Finland. (34,35)

The quality of the results derived from a PAF analysis is inevitably limited by the quality of the inputs, specifically RR and prevalence data. A potential weakness in this study is the lack of RR information based on Canadian data. A sensitivity analysis using the 95% CI associated with each RR indicates the importance of using robust and accurate RR estimates. The economic modelling also uses older data from CIHI and the EBIC for cost allocation purposes, requiring the assumption that the distribution of costs have not changed significantly for specific cost categories over time. Similarly, the method of scaling up from direct costs to indirect costs depends on the assumption that the ratios of costs between different co-morbidities are the same for direct and indirect costs.

Received: June 6, 2013 Accepted: January 28, 2014

Conflict of Interest: None to declare.

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Hans Krueger, PhD, [1,2] Donna Turner, PhD, [3,4] Joshua Krueger, BA, [2] A. Elizabeth Ready, PhD [5]

Author Affiliations

[1.] School of Population and Public Health, University of British Columbia, Vancouver, BC

[2.] H. Krueger & Associates Inc., Delta, BC

[3.] Department of Community Health Sciences, University of Manitoba, Winnipeg, MB

[4.] CancerCare Manitoba, Winnipeg, MB

[5.] Faculty of Kinesiology and Recreation Management, University of Manitoba, Winnipeg, MB

Correspondence: Hans Krueger, H. Krueger & Associates Inc., 4554 48B Street, Delta, BC V4K 2R8, Tel: 604-946-5464, E-mail: hans@krueger.ca

Table 1. Relative risk, prevalence of risk factors, and population
attributable fraction in Canada, 2010

                                               Tobacco smoking

                                                    Light

                                                    Male
Prevalence of Risk Factor in Canada in 2010         8.3%

                                                   All ages

Cancers                      ICD-9 Code         RR       PAF
  Trachea, bronchus, lung    162              10.83     21.4%
  Lip, oral cavity,          140-149,          2.85      9.6%
    pharynx, larynx            160,161
  Urinary bladder            188               2.68      9.7%
  Esophagus                  150               2.17      7.1%
  Pancreas                   157               1.89      5.9%
  Stomach                    151               1.75      5.2%
  Liver                      155               1.42      3.1%
  Kidney, other urinary      189               1.42      3.0%
  Colorectal cancer          153, 154          1.20      1.6%
  Breast cancer              174, 175
  Postmenopausal breast      174, 175
    cancer
  Endometrial cancer         179, 181,
                               182
  Ovarian cancer             183
Cardiovascular Diseases
  Aortic aneurysm            441               3.87     12.7%
  Coronary heart disease     410-414, 429      3.19     11.2%
  Stroke/cerebrovascular     430-438           2.29      7.8%
    disease
  Venous thromboembolism     415,451-453       1.34      2.6%
  Pulmonary embolism         415.1
  Congestive heart failure   428
  Hypertension               401-405
Respiratory Diseases
  Chronic lung disease       490-492,         22.71     27.1%
                               493.2
  Pneumonia, influenza       480-486           2.06      6.5%
  Asthma                     493
Diabetes
  Type 2 diabetes            250.x0,
                               250.x2
Other
  Cirrhosis of alcoholic     571.0,.1,.2,.     2.73      9.8%
    liver                      3,.5,.6,.9
  Gallbladder disease        574, 575
  Osteoarthritis             715
  Chronic back pain          720-724

                                               Tobacco smoking

                                                    Light

                                                    Female
Prevalence of Risk Factor in Canada in 2010         7.0%

                                                   All ages

Cancers                      ICD-9 Code         RR       PAF
  Trachea, bronchus, lung    162              10.83     21.0%
  Lip, oral cavity,          140-149,          2.85      8.9%
    pharynx, larynx            160,161
  Urinary bladder            188               2.68      8.9%
  Esophagus                  150               2.17      6.5%
  Pancreas                   157               1.89      5.3%
  Stomach                    151               1.75      4.6%
  Liver                      155               1.42      2.7%
  Kidney, other urinary      189               1.42      2.6%
  Colorectal cancer          153, 154          1.20      1.4%
  Breast cancer              174, 175
  Postmenopausal breast      174, 175
    cancer
  Endometrial cancer         179, 181,
                               182
  Ovarian cancer             183
Cardiovascular Diseases
  Aortic aneurysm            441               3.87     12.1%
  Coronary heart disease     410-414, 429      3.19     10.4%
  Stroke/cerebrovascular     430-438           2.29      7.1%
    disease
  Venous thromboembolism     415,451-453       1.34      2.2%
  Pulmonary embolism         415.1
  Congestive heart failure   428
  Hypertension               401-405
Respiratory Diseases
  Chronic lung disease       490-492,         22.71     27.0%
                               493.2
  Pneumonia, influenza       480-486           2.06      5.9%
  Asthma                     493
Diabetes
  Type 2 diabetes            250.x0,
                               250.x2
Other
  Cirrhosis of alcoholic     571.0,.1,.2,.     2.73      9.1%
    liver                      3,.5,.6,.9
  Gallbladder disease        574, 575
  Osteoarthritis             715
  Chronic back pain          720-724

                                               Tobacco smoking

                                                   Moderate

                                                    Male
Prevalence of Risk Factor in Canada in 2010         5.9%

                                                   All ages

Cancers                      ICD-9 Code         RR       PAF
  Trachea, bronchus, lung    162              22.03     26.6%
  Lip, oral cavity,          140-149,          4.91     13.6%
    pharynx, larynx            160,161
  Urinary bladder            188               3.66     10.8%
  Esophagus                  150               2.99      8.5%
  Pancreas                   157               2.37      6.5%
  Stomach                    151               2.04      5.2%
  Liver                      155               1.56      3.0%
  Kidney, other urinary      189               2.28      6.3%
  Colorectal cancer          153, 154          1.22      1.2%
  Breast cancer              174, 175
  Postmenopausal breast      174, 175
    cancer
  Endometrial cancer         179, 181,
                               182
  Ovarian cancer             183
Cardiovascular Diseases
  Aortic aneurysm            441               7.18     17.8%
  Coronary heart disease     410-414, 429      4.55     12.7%
  Stroke/cerebrovascular     430-438           3.20      9.3%
    disease
  Venous thromboembolism     415,451-453       1.39      2.1%
  Pulmonary embolism         415.1
  Congestive heart failure   428
  Hypertension               401-405
Respiratory Diseases
  Chronic lung disease       490-492,         32.87     27.6%
                               493.2
  Pneumonia, influenza       480-486           3.06      8.8%
  Asthma                     493
Diabetes
  Type 2 diabetes            250.x0,           1.86      4.6%
                               250.x2
Other
  Cirrhosis of alcoholic     571.0,.1,.2,.     3.34      9.6%
    liver                      3,.5,.6,.9
  Gallbladder disease        574, 575
  Osteoarthritis             715
  Chronic back pain          720-724

                                               Tobacco smoking

                                                   Moderate

                                                     Female
Prevalence of Risk Factor in Canada in 2010          5.0%

                                                   All ages

Cancers                      ICD-9 Code         RR        PAF
  Trachea, bronchus, lung    162               22.03     26.2%
  Lip, oral cavity,          140-149,           4.91     12.6%
    pharynx, larynx            160,161
  Urinary bladder            188                3.66      9.9%
  Esophagus                  150                2.99      7.7%
  Pancreas                   157                2.37      5.7%
  Stomach                    151                2.04      4.5%
  Liver                      155                1.56      2.6%
  Kidney, other urinary      189                2.28      5.5%
  Colorectal cancer          153, 154           1.22      1.1%
  Breast cancer              174, 175           1.15      0.7%
  Postmenopausal breast      174, 175
    cancer
  Endometrial cancer         179, 181,
                               182
  Ovarian cancer             183
Cardiovascular Diseases
  Aortic aneurysm            441                7.18     17.0%
  Coronary heart disease     410-414, 429       4.55     11.8%
  Stroke/cerebrovascular     430-438            3.20      8.4%
    disease
  Venous thromboembolism     415,451-453        1.39      1.8%
  Pulmonary embolism         415.1
  Congestive heart failure   428
  Hypertension               401-405
Respiratory Diseases
  Chronic lung disease       490-492,          32.87     27.4%
                               493.2
  Pneumonia, influenza       480-486            3.06      7.9%
  Asthma                     493
Diabetes
  Type 2 diabetes            250.x0,            1.86      3.9%
                               250.x2
Other
  Cirrhosis of alcoholic     571.0,.1,.2,.      3.34      8.7%
    liver                      3,.5,.6,.9
  Gallbladder disease        574, 575
  Osteoarthritis             715
  Chronic back pain          720-724

                                               Tobacco smoking

                                                    Heavy

                                                     Male
Prevalence of Risk Factor in Canada in 2010          6.5%

                                                   All ages

Cancers                      ICD-9 Code         RR        PAF
  Trachea, bronchus, lung    162               36.00     33.3%
  Lip, oral cavity,          140-149,           7.20     20.9%
    pharynx, larynx            160,161
  Urinary bladder            188                3.24     10.2%
  Esophagus                  150                4.62     15.5%
  Pancreas                   157                2.66      8.4%
  Stomach                    151                2.20      6.5%
  Liver                      155                1.54      3.2%
  Kidney, other urinary      189                2.56      8.2%
  Colorectal cancer          153, 154           1.39      2.4%
  Breast cancer              174, 175
  Postmenopausal breast      174, 175
    cancer
  Endometrial cancer         179, 181,
                               182
  Ovarian cancer             183
Cardiovascular Diseases
  Aortic aneurysm            441                8.09     21.1%
  Coronary heart disease     410-414, 429       5.92     17.8%
  Stroke/cerebrovascular     430-438            3.81     12.5%
    disease
  Venous thromboembolism     415,451-453        1.77      4.5%
  Pulmonary embolism         415.1
  Congestive heart failure   428
  Hypertension               401-405
Respiratory Diseases
  Chronic lung disease       490-492,          60.49     33.6%
                               493.2
  Pneumonia, influenza       480-486            4.42     14.8%
  Asthma                     493
Diabetes
  Type 2 diabetes            250.x0,            2.17      6.7%
                               250.x2
Other
  Cirrhosis of alcoholic     571.0,.1,.2,.      3.97     12.8%
    liver                      3,.5,.6,.9
  Gallbladder disease        574, 575
  Osteoarthritis             715
  Chronic back pain          720-724

                                               Tobacco smoking

                                                    Heavy

                                                    Female
Prevalence of Risk Factor in Canada in 2010          3.0%

                                                   All ages

Cancers                      ICD-9 Code         RR        PAF
  Trachea, bronchus, lung    162               36.00     26.5%
  Lip, oral cavity,          140-149,           7.20     12.3%
    pharynx, larynx            160,161
  Urinary bladder            188                3.24      5.4%
  Esophagus                  150                4.62      8.5%
  Pancreas                   157                2.66      4.3%
  Stomach                    151                2.20      3.2%
  Liver                      155                1.54      1.5%
  Kidney, other urinary      189                2.56      4.2%
  Colorectal cancer          153, 154           1.39      1.1%
  Breast cancer              174, 175           1.25      0.8%
  Postmenopausal breast      174, 175
    cancer
  Endometrial cancer         179, 181,
                               182
  Ovarian cancer             183
Cardiovascular Diseases
  Aortic aneurysm            441                8.09     12.9%
  Coronary heart disease     410-414, 429       5.92     10.2%
  Stroke/cerebrovascular     430-438            3.81      6.7%
    disease
  Venous thromboembolism     415,451-453        1.77      2.2%
  Pulmonary embolism         415.1
  Congestive heart failure   428
  Hypertension               401-405
Respiratory Diseases
  Chronic lung disease       490-492,          60.49     28.8%
                               493.2
  Pneumonia, influenza       480-486            4.42      8.1%
  Asthma                     493
Diabetes
  Type 2 diabetes            250.x0,            2.17      3.3%
                               250.x2
Other
  Cirrhosis of alcoholic     571.0,.1,.2,.      3.97      6.9%
    liver                      3,.5,.6,.9
  Gallbladder disease        574, 575
  Osteoarthritis             715
  Chronic back pain          720-724

                                                 Excess weight

                                                  Overweight

                                                     Male
Prevalence of Risk Factor in Canada in 2010          34.7%

                                                   All ages

Cancers                      ICD-9 Code         RR        PAF
  Trachea, bronchus, lung    162
  Lip, oral cavity,          140-149,
    pharynx, larynx            160,161
  Urinary bladder            188
  Esophagus                  150                 1.13     4.3%
  Pancreas                   157
  Stomach                    151
  Liver                      155
  Kidney, other urinary      189                1.40     10.9%
  Colorectal cancer          153, 154           1.51     13.2%
  Breast cancer              174, 175
  Postmenopausal breast      174, 175
    cancer
  Endometrial cancer         179, 181,
                               182
  Ovarian cancer             183
Cardiovascular Diseases
  Aortic aneurysm            441
  Coronary heart disease     410-414, 429       1.29      4.7%
  Stroke/cerebrovascular     430-438            1.23      6.9%
    disease
  Venous thromboembolism     415,451-453
  Pulmonary embolism         415.1              1.91     19.0%
  Congestive heart failure   428
  Hypertension               401-405            1.28      4.5%
Respiratory Diseases
  Chronic lung disease       490-492,
                               493.2
  Pneumonia, influenza       480-486
  Asthma                     493                1.20      6.1%
Diabetes
  Type 2 diabetes            250.x0,            2.40     16.1%
                               250.x2
Other
  Cirrhosis of alcoholic     571.0,.1,.2,.
    liver                      3,.5,.6,.9
  Gallbladder disease        574, 575
  Osteoarthritis             715                2.76     27.9%
  Chronic back pain          720-724            1.59     14.3%

                                                 Excess weight

                                                  Overweight

                                                    Female
Prevalence of Risk Factor in Canada in 2010          22.5%

                                                   All ages

Cancers                      ICD-9 Code         RR        PAF
  Trachea, bronchus, lung    162
  Lip, oral cavity,          140-149,
    pharynx, larynx            160,161
  Urinary bladder            188
  Esophagus                  150
  Pancreas                   157
  Stomach                    151
  Liver                      155
  Kidney, other urinary      189                1.82     13.4%
  Colorectal cancer          153, 154           1.45      8.5%
  Breast cancer              174, 175
  Postmenopausal breast      174, 175           1.08      1.7%
    cancer
  Endometrial cancer         179, 181,          1.53      9.3%
                               182
  Ovarian cancer             183                1.18      3.8%
Cardiovascular Diseases
  Aortic aneurysm            441
  Coronary heart disease     410-414, 429       1.80      8.6%
  Stroke/cerebrovascular     430-438            1.15      3.1%
    disease
  Venous thromboembolism     415,451-453
  Pulmonary embolism         415.1              1.91     14.2%
  Congestive heart failure   428
  Hypertension               401-405            1.65      7.3%
Respiratory Diseases
  Chronic lung disease       490-492,
                               493.2
  Pneumonia, influenza       480-486
  Asthma                     493                1.25      5.0%
Diabetes
  Type 2 diabetes            250.x0,            3.92     21.0%
                               250.x2
Other
  Cirrhosis of alcoholic     571.0,.1,.2,.
    liver                      3,.5,.6,.9
  Gallbladder disease        574, 575           1.44      5.2%
  Osteoarthritis             715                1.80     13.5%
  Chronic back pain          720-724            1.59     10.3%

                                                 Excess weight

                                                   Obesity

                                                     Male
Prevalence of Risk Factor in Canada in 2010          16.0%

                                                   All ages

Cancers                      ICD-9 Code         RR        PAF
  Trachea, bronchus, lung    162
  Lip, oral cavity,          140-149,
    pharynx, larynx            160,161
  Urinary bladder            188
  Esophagus                  150
  Pancreas                   157                2.29     17.1%
  Stomach                    151
  Liver                      155
  Kidney, other urinary      189                1.82     10.4%
  Colorectal cancer          153, 154           1.95     11.6%
  Breast cancer              174, 175
  Postmenopausal breast      174, 175
    cancer
  Endometrial cancer         179, 181,
                               182
  Ovarian cancer             183
Cardiovascular Diseases
  Aortic aneurysm            441
  Coronary heart disease     410-414, 429       1.72      8.6%
  Stroke/cerebrovascular     430-438            1.51      7.0%
    disease
  Venous thromboembolism     415,451-453
  Pulmonary embolism         415.1              3.51     22.7%
  Congestive heart failure   428                1.79     11.2%
  Hypertension               401-405            1.84      9.9%
Respiratory Diseases
  Chronic lung disease       490-492,
                               493.2
  Pneumonia, influenza       480-486
  Asthma                     493                1.43      6.1%
Diabetes
  Type 2 diabetes            250.x0,            6.74     35.4%
                               250.x2
Other
  Cirrhosis of alcoholic     571.0,.1,.2,.
    liver                      3,.5,.6,.9
  Gallbladder disease        574, 575           1.43      5.7%
  Osteoarthritis             715                4.20     25.0%
  Chronic back pain          720-724            2.81     18.8%

                                                 Excess weight

                                                   Obesity

                                                     Female
Prevalence of Risk Factor in Canada in 2010          12.8%

                                                   All ages

Cancers                      ICD-9 Code         RR        PAF
  Trachea, bronchus, lung    162
  Lip, oral cavity,          140-149,
    pharynx, larynx            160,161
  Urinary bladder            188
  Esophagus                  150
  Pancreas                   157                1.60      7.1%
  Stomach                    151
  Liver                      155
  Kidney, other urinary      189                2.64     14.9%
  Colorectal cancer          153, 154           1.66      7.2%
  Breast cancer              174, 175
  Postmenopausal breast      174, 175            1.13     1.6%
    cancer
  Endometrial cancer         179, 181,          3.22     19.3%
                               182
  Ovarian cancer             183                1.28      3.3%
Cardiovascular Diseases
  Aortic aneurysm            441
  Coronary heart disease     410-414, 429       3.10     18.7%
  Stroke/cerebrovascular     430-438            1.49      5.6%
    disease
  Venous thromboembolism     415,451-453
  Pulmonary embolism         415.1              3.51     20.2%
  Congestive heart failure   428                1.78      9.0%
  Hypertension               401-405            2.42     13.9%
Respiratory Diseases
  Chronic lung disease       490-492,
                               493.2
  Pneumonia, influenza       480-486
  Asthma                     493                1.78      8.5%
Diabetes
  Type 2 diabetes            250.x0,            2.41     43.9%
                               250.x2
Other
  Cirrhosis of alcoholic     571.0,.1,.2,.
    liver                      3,.5,.6,.9
  Gallbladder disease        574, 575           2.32     13.4%
  Osteoarthritis             715                1.96      9.7%
  Chronic back pain          720-724            2.81     16.4%

                                                   Physical
                                                  inactivity

                                                     Male
Prevalence of Risk Factor in Canada in 2010          41.1%

                                                   All ages

Cancers                      ICD-9 Code         RR        PAF
  Trachea, bronchus, lung    162
  Lip, oral cavity,          140-149,
    pharynx, larynx            160,161
  Urinary bladder            188
  Esophagus                  150
  Pancreas                   157
  Stomach                    151
  Liver                      155
  Kidney, other urinary      189
  Colorectal cancer          153, 154           1.41     14.4%
  Breast cancer              174, 175
  Postmenopausal breast      174, 175
    cancer
  Endometrial cancer         179, 181,
                               182
  Ovarian cancer             183
Cardiovascular Diseases
  Aortic aneurysm            441
  Coronary heart disease     410-414, 429       1.45     15.6%
  Stroke/cerebrovascular     430-438            1.60     19.8%
    disease
  Venous thromboembolism     415,451-453
  Pulmonary embolism         415.1
  Congestive heart failure   428
  Hypertension               401-405            1.30     11.0%
Respiratory Diseases
  Chronic lung disease       490-492,
                               493.2
  Pneumonia, influenza       480-486
  Asthma                     493
Diabetes
  Type 2 diabetes            250.x0,            1.50     17.0%
                               250.x2
Other
  Cirrhosis of alcoholic     571.0,.1,.2,.
    liver                      3,.5,.6,.9
  Gallbladder disease        574, 575
  Osteoarthritis             715                1.59     19.5%
  Chronic back pain          720-724

                                                   Physical
                                                  inactivity

                                                     Female
Prevalence of Risk Factor in Canada in 2010          47.5%

                                                   All ages

Cancers                      ICD-9 Code         RR        PAF
  Trachea, bronchus, lung    162
  Lip, oral cavity,          140-149,
    pharynx, larynx            160,161
  Urinary bladder            188
  Esophagus                  150
  Pancreas                   157
  Stomach                    151
  Liver                      155
  Kidney, other urinary      189
  Colorectal cancer          153, 154           1.41     16.3%
  Breast cancer              174, 175           1.31     12.8%
  Postmenopausal breast      174, 175
    cancer
  Endometrial cancer         179, 181,
                               182
  Ovarian cancer             183
Cardiovascular Diseases
  Aortic aneurysm            441
  Coronary heart disease     410-414, 429       1.45     17.6%
  Stroke/cerebrovascular     430-438            1.60     22.2%
    disease
  Venous thromboembolism     415,451-453
  Pulmonary embolism         415.1
  Congestive heart failure   428
  Hypertension               401-405            1.30     12.5%
Respiratory Diseases
  Chronic lung disease       490-492,
                               493.2
  Pneumonia, influenza       480-486
  Asthma                     493
Diabetes
  Type 2 diabetes            250.x0,            1.50     19.2%
                               250.x2
Other
  Cirrhosis of alcoholic     571.0,.1,.2,.
    liver                      3,.5,.6,.9
  Gallbladder disease        574, 575
  Osteoarthritis             715                1.59     21.9%
  Chronic back pain          720-724

ICD = International Classification of Disease; RR = Relative Risk;
PAF = Population Attributable Fraction.

Table 2. Estimated prevalence of RFs, total economic burden
for multifactorial system, and disaggregated costs by RF
Canada, 2012, by sex, adjusted for multiple RFs in one individual

                                       %             #
                                   Population   Individuals
                                    with RF       with RF

Males
  Smokers
    Light                             8.3%       1,435,035
    Moderate                          5.9%       1,024,846
    Heavy                             6.5%       1,129,249
  Subtotal--Male Smokers             20.7%       3,589,130
  Excess Weight
    Overweight                       34.7%       6,046,660
    Obese                            16.0%       2,773,601
  Subtotal--Male Excess Weight       50.7%       8,820,261
  Inactive                           41.1%       7,149,313
  Subtotal

Females
  Smokers
    Light                             7.0%       1,227,115
    Moderate                          5.0%         867,893
    Heavy                             3.0%         530,887
  Subtotal--Female Smokers           15.0%       2,625,894
  Excess Weight
    Overweight                       22.5%       3,987,187
    Obesity                          12.8%       2,258,665
  Subtotal--Female Excess Weight     35.3%       6,245,852
  Inactive                           47.5%       8,409,362
  Subtotal

Both Sexes
  Smokers
    Light                             7.6%       2,662,149
    Moderate                          5.4%       1,892,739
    Heavy                             4.8%       1,660,137
  Subtotal--Smokers                  17.9%       6,215,024
  Excess Weight
    Overweight                       28.6%      10,033,847
    Obesity                          14.4%       5,032,267
  Subtotal--Excess Weight            42.9%      15,066,113
  Inactive                           44.3%      15,558,675
  Total

                                     Direct      Indirect
                                    cost per     cost per
                                   individual   individual
                                    with RF      with RF
                                     ($'s)        ($'s)

Males
  Smokers
    Light                              $767       $1,598
    Moderate                         $1,279       $2,669
    Heavy                            $1,598       $3,283
  Subtotal--Male Smokers             $1,175       $2,434
  Excess Weight
    Overweight                         $156         $468
    Obese                              $565       $1,384
  Subtotal--Male Excess Weight         $285         $756
  Inactive                             $195         $422
  Subtotal

Females
  Smokers
    Light                              $681       $1,366
    Moderate                         $1,144       $2,315
    Heavy                            $1,753       $3,562
  Subtotal--Female Smokers           $1,051       $2,124
  Excess Weight
    Overweight                         $256         $685
    Obesity                            $842       $1,863
  Subtotal--Female Excess Weight       $468       $1,111
  Inactive                             $191         $472
  Subtotal

Both Sexes
  Smokers
    Light                              $727       $1,491
    Moderate                         $1,217       $2,507
    Heavy                            $1,648       $3,372
  Subtotal--Smokers                  $1,122       $2,303
  Excess Weight
    Overweight                         $196         $554
    Obesity                            $689       $1,599
  Subtotal--Excess Weight              $361         $903
  Inactive                             $193         $449
  Total

                                     Total         Total
                                    cost per      direct
                                   individual     cost of
                                    with RF         RF
                                     ($'s)      (million $)

Males
  Smokers
    Light                            $2,365        $1,100
    Moderate                         $3,948        $1,311
    Heavy                            $4,881        $1,805
  Subtotal--Male Smokers             $3,609        $4,216
  Excess Weight
    Overweight                         $624          $945
    Obese                            $1,949        $1,567
  Subtotal--Male Excess Weight       $1,041        $2,513
  Inactive                             $618        $1,397
  Subtotal                                         $8,125

Females
  Smokers
    Light                            $2,047          $836
    Moderate                         $3,459          $992
    Heavy                            $5,315          $930
  Subtotal--Female Smokers           $3,174        $2,759
  Excess Weight
    Overweight                         $940        $1,020
    Obesity                          $2,705        $1,901
  Subtotal--Female Excess Weight     $1,579        $2,921
  Inactive                             $663        $1,603
  Subtotal                                         $7,282

Both Sexes
  Smokers
    Light                            $2,218        $1,936
    Moderate                         $3,724        $2,303
    Heavy                            $5,020        $2,735
  Subtotal--Smokers                  $3,425        $6,974
  Excess Weight
    Overweight                         $750        $1,965
    Obesity                          $2,288        $3,468
  Subtotal--Excess Weight            $1,264        $5,433
  Inactive                             $642        $3,000
  Total                                           $15,408

                                      Total         Total
                                    indirect       cost of
                                     cost of         RF
                                       RF        (million $)
                                   (million $)

Males
  Smokers
    Light                             $2,294        $3,394
    Moderate                          $2,735        $4,046
    Heavy                             $3,707        $5,512
  Subtotal--Male Smokers              $8,736       $12,952
  Excess Weight
    Overweight                        $2,827        $3,772
    Obese                             $3,838        $5,406
  Subtotal--Male Excess Weight        $6,665        $9,178
  Inactive                            $3,020        $4,417
  Subtotal                           $18,422       $26,547

Females
  Smokers
    Light                             $1,676        $2,512
    Moderate                          $2,009        $3,002
    Heavy                             $1,891        $2,822
  Subtotal--Female Smokers            $5,577        $8,336
  Excess Weight
    Overweight                        $2,730        $3,750
    Obesity                           $4,209        $6,109
  Subtotal--Female Excess Weight      $6,939        $9,859
  Inactive                            $3,968        $5,571
  Subtotal                           $16,484       $23,766

Both Sexes
  Smokers
    Light                             $3,970        $5,906
    Moderate                          $4,744        $7,048
    Heavy                             $5,599        $8,334
  Subtotal--Smokers                  $14,313       $21,288
  Excess Weight
    Overweight                        $5,557        $7,522
    Obesity                           $8,047       $11,515
  Subtotal--Excess Weight            $13,604       $19,037
  Inactive                            $6,988        $9,988
  Total                              $34,906       $50,313

RF = Risk factor.

Table 3. Projected risk factor prevalence, Canada,
2012 compared with 2031 (no change) & 2031 (1% reduction)

                                              2012

                                  % Population   # Individuals
                                    with RF         with RF

Males
  Smokers
    Light                             8.3%         1,435,035
    Moderate                          5.9%         1,024,846
    Heavy                             6.5%         1,129,249
  Subtotal--Male Smokers             20.7%         3,589,130
  Excess Weight
    Overweight                       34.7%         6,046,660
    Obese                            16.0%         2,773,601
  Subtotal--Male Excess Weight       50.7%         8,820,261
  Inactive                           41.1%         7,149,313
  Subtotal
Females
  Smokers
    Light                             7.0%         1,227,115
    Moderate                          5.0%           867,893
    Heavy                             3.0%           530,887
  Subtotal--Female Smokers           15.0%         2,625,894
  Excess Weight
    Overweight                       22.5%         3,987,187
    Obesity                          12.8%         2,258,665
  Subtotal--Female Excess Weight     35.3%         6,245,852
  Inactive                           47.5%         8,409,362
Both Sexes
  Smokers
    Light                             7.6%         2,662,149
    Moderate                          5.4%         1,892,739
    Heavy                             4.8%         1,660,137
  Subtotal--Smokers                  17.9%         6,215,024
  Excess Weight
    Overweight                       28.6%        10,033,847
    Obesity                          14.4%         5,032,267
  Subtotal--Excess Weight            42.9%        15,066,113
  Inactive                           44.3%        15,558,675

                                        2031 (No Change)

                                  % Population   # Individuals
                                    with RF         with RF

Males
  Smokers
    Light                             7.6%          1,594,064
    Moderate                          5.6%          1,159,318
    Heavy                             6.1%          1,263,547
  Subtotal--Male Smokers             19.3%          4,016,929
  Excess Weight
    Overweight                       35.0%          7,306,670
    Obese                            15.6%          3,258,843
  Subtotal--Male Excess Weight       50.7%         10,565,513
  Inactive                           41.6%          8,683,597
  Subtotal
Females
  Smokers
    Light                             6.5%          1,372,665
    Moderate                          4.7%            994,982
    Heavy                             2.9%            611,023
  Subtotal--Female Smokers           14.0%          2,978,670
  Excess Weight
    Overweight                       23.7%          4,927,711
    Obesity                          13.2%          2,754,174
  Subtotal--Female Excess Weight     36.9%          7,681,885
  Inactive                           48.8%         10,358,354
Both Sexes
  Smokers
    Light                             7.0%          2,966,729
    Moderate                          5.1%          2,154,300
    Heavy                             4.5%          1,874,569
  Subtotal--Smokers                  16.6%          6,995,599
  Excess Weight
    Overweight                       29.4%         12,234,381
    Obesity                          14.4%          6,013,017
  Subtotal--Excess Weight            43.8%         18,247,398
  Inactive                           45.2%         19,041,951

                                       2031 (1% Reduction)

                                  % Population   # Individuals
                                    with RF         with RF

Males
  Smokers
    Light                             6.3%         1,305,506
    Moderate                          4.6%           950,121
    Heavy                             5.0%         1,033,028
  Subtotal--Male Smokers             15.8%         3,288,655
  Excess Weight
    Overweight                       31.7%         6,605,100
    Obese                            12.9%         2,679,466
  Subtotal--Male Excess Weight       44.5%         9,284,567
  Inactive                           34.5%         7,183,620
  Subtotal
Females
  Smokers
    Light                             5.3%         1,124,630
    Moderate                          3.8%           816,662
    Heavy                             2.4%           501,892
  Subtotal--Female Smokers           11.5%         2,443,184
  Excess Weight
    Overweight                       21.9%         4,556,455
    Obesity                          10.9%         2,271,475
  Subtotal--Female Excess Weight     32.8%         6,827,931
  Inactive                           40.4%         8,585,838
Both Sexes
  Smokers
    Light                             5.8%         2,430,136
    Moderate                          4.2%         1,766,783
    Heavy                             3.6%         1,534,920
  Subtotal--Smokers                  13.6%         5,731,839
  Excess Weight
    Overweight                       26.8%        11,161,556
    Obesity                          11.9%         4,950,942
  Subtotal--Excess Weight            38.7%        16,112,497
  Inactive                           37.5%        15,769,458

Table 4. Projected economic burden of smoking, excess weight and
physical inactivity, Canada, 2012 compared with 2031 (no change)
& 2031 (1% reduction), 2012 constant dollars

                                                 2012

                                     Total       Total       Total
                                    direct     indirect     cost of
                                    cost of     cost of    RF (MS's)
                                   RF (MS's)   RF (MS's)
Males
  Smokers
    Light                            $1,100      $2,294      $3,394
    Moderate                         $1,311      $2,735      $4,046
    Heavy                            $1,805      $3,707      $5,512
  Subtotal--Male Smokers             $4,216      $8,736     $12,952
  Excess Weight
    Overweight                         $945      $2,827      $3,772
    Obese                            $1,567      $3,838      $5,406
  Subtotal--Male Excess Weight       $2,513      $6,665      $9,178
  Inactive                           $1,397      $3,020      $4,417
  Subtotal                           $8,125     $18,422     $26,547
Females
  Smokers
    Light                              $836      $1,676      $2,512
    Moderate                           $992      $2,009      $3,002
    Heavy                              $930      $1,891      $2,822
  Subtotal--Female Smokers           $2,759      $5,577      $8,336
  Excess Weight
    Overweight                       $1,020      $2,730      $3,750
    Obesity                          $1,901      $4,209      $6,109
  Subtotal--Female Excess Weight     $2,921      $6,939      $9,859
  Inactive                           $1,603      $3,968      $5,571
  Subtotal                           $7,282     $16,484     $23,766
Both Sexes
    Smokers
    Light                            $1,936      $3,970      $5,906
    Moderate                         $2,303      $4,744      $7,048
    Heavy                            $2,735      $5,599      $8,334
  Subtotal--Smokers                  $6,974     $14,313     $21,288
  Excess Weight
    Overweight                       $1,965      $5,557      $7,522
    Obesity                          $3,468      $8,047     $11,515
  Subtotal--Excess Weight            $5,433     $13,604     $19,037
  Inactive                           $3,000      $6,988      $9,988
  Total                             $15,408     $34,906     $50,313

                                           2031 (No Change)

                                     Total       Total       Total
                                    direct     indirect     cost of
                                    cost of     cost of    RF (MS's)
                                   RF (MS's)   RF (MS's)
Males
  Smokers
    Light                            $1,222      $2,548       $3,770
    Moderate                         $1,483      $3,094       $4,577
    Heavy                            $2,019      $4,148       $6,168
  Subtotal--Male Smokers             $4,724      $9,790      $14,515
  Excess Weight
    Overweight                       $1,142      $3,416       $4,558
    Obese                            $1,842      $4,510       $6,352
  Subtotal--Male Excess Weight       $2,984      $7,926      $10,910
  Inactive                           $1,696      $3,669       $5,365
  Subtotal                           $9,405     $21,385      $30,789
Females
  Smokers
    Light                              $935      $1,875       $2,810
    Moderate                         $1,138      $2,303       $3,441
    Heavy                            $1,071      $2,177       $3,248
  Subtotal--Female Smokers           $3,144      $6,356       $9,499
  Excess Weight
    Overweight                       $1,261      $3,374       $4,634
    Obesity                          $2,318      $5,132       $7,450
  Subtotal--Female Excess Weight     $3,578      $8,506      $12,084
  Inactive                           $1,975      $4,888       $6,862
  Subtotal                           $8,697     $19,749      $28,446
Both Sexes
    Smokers
    Light                            $2,157      $4,423       $6,580
    Moderate                         $2,621      $5,397       $8,018
    Heavy                            $3,090      $6,325       $9,416
  Subtotal--Smokers                  $7,868     $16,146      $24,014
  Excess Weight
    Overweight                       $2,403      $6,790       $9,193
    Obesity                          $4,159      $9,642      $13,801
  Subtotal--Excess Weight            $6,562     $16,432      $22,994
  Inactive                           $3,671      $8,556      $12,227
  Total                             $18,101     $41,134      $59,235

                                         2031 (1% Reduction)

                                      Total       Total       Total
                                     direct     indirect     cost of
                                     cost of     cost of    RF (MS's)
                                    RF (MS's)   RF (MS's)
Males
  Smokers
    Light                            $1,058      $2,211       $3,269
    Moderate                         $1,285      $2,686       $3,971
    Heavy                            $1,746      $3,596       $5,342
  Subtotal--Male Smokers             $4,089      $8,493      $12,582
  Excess Weight
    Overweight                       $1,033      $3,088       $4,121
    Obese                            $1,514      $3,708       $5,222
  Subtotal--Male Excess Weight       $2,547      $6,796       $9,343
  Inactive                           $1,403      $3,035       $4,438
  Subtotal                           $8,039     $18,324      $26,363
Females
  Smokers
    Light                              $814      $1,634       $2,448
    Moderate                           $992      $2,010       $3,002
    Heavy                              $934      $1,901       $2,835
  Subtotal--Female Smokers           $2,740      $5,544       $8,285
  Excess Weight
    Overweight                       $1,166      $3,120       $4,285
    Obesity                          $1,912      $4,233       $6,144
  Subtotal--Female Excess Weight     $3,077      $7,352      $10,429
  Inactive                           $1,637      $4,051       $5,688
  Subtotal                           $7,454     $16,948      $24,402
Both Sexes
    Smokers
    Light                            $1,872      $3,845       $5,717
    Moderate                         $2,277      $4,696       $6,973
    Heavy                            $2,681      $5,496       $8,177
  Subtotal--Smokers                  $6,829     $14,038      $20,867
  Excess Weight
    Overweight                       $2,198      $6,208       $8,406
    Obesity                          $3,426      $7,941      $11,367
  Subtotal--Excess Weight            $5,624     $14,148      $19,772
  Inactive                           $3,040      $7,086      $10,126
  Total                             $15,493     $35,272      $50,765

RF = Risk factor.

Table 5. Estimated total economic burden for multifactorial system,
and disaggregated costs by RF, Canada, 2012, by sex, sensitivity
analysis ($Millions)

                                     Best       Low       Variance
                                   Estimate   Estimate
                                    of RR      of RR
Males
  Smokers
    Light                           $3,394     $3,014       -$380
    Moderate                        $4,046     $3,908       -$138
    Heavy                           $5,512     $5,259       -$253
  Subtotal--Male Smokers           $12,952    $12,181       -$771
  Excess Weight
    Overweight                      $3,772     $2,718     -$1,054
    Obese                           $5,406     $3,919     -$1,487
  Subtotal--Male Excess Weight      $9,178     $6,638     -$2,541
  Inactive                          $4,417     $3,504       -$913
  Subtotal                         $26,547    $22,323    ($4,224)
Females
    Smokers
    Light                           $2,512     $2,234       -$278
    Moderate                        $3,002     $2,874       -$128
    Heavy                           $2,822     $2,677       -$145
  Subtotal--Female Smokers          $8,336     $7,785       -$551
  Excess Weight
    Overweight                      $3,750     $2,686     -$1,064
    Obesity                         $6,109     $4,520     -$1,589
  Subtotal--Female Excess Weight    $9,859     $7,206     -$2,653
  Inactive                          $5,571     $4,312     -$1,260
  Subtotal                         $23,766    $19,303    ($4,463)
Both Sexes
  Smokers
    Light                           $5,906     $5,248       -$658
    Moderate                        $7,048     $6,782       -$265
    Heavy                           $8,334     $7,936       -$398
  Subtotal--Smokers                $21,288    $19,966     -$1,321
    Excess Weight
    Overweight                      $7,522     $5,405     -$2,117
    Obesity                        $11,515     $8,439     -$3,076
  Subtotal--Excess Weight          $19,037    $13,844     -$5,193
  Inactive                          $9,988     $7,816     -$2,172
  Total                            $50,313    $41,626    ($8,687)

                                   % Var.     High
                                            Estimate
                                             of RR
Males
  Smokers
    Light                          -11.2%     $3,770
    Moderate                        -3.4%     $4,177
    Heavy                           -4.6%     $5,762
  Subtotal--Male Smokers            -5.9%    $13,710
  Excess Weight
    Overweight                     -27.9%     $4,671
    Obese                          -27.5%     $6,850
  Subtotal--Male Excess Weight     -27.7%    $11,521
  Inactive                         -20.7%     $5,309
  Subtotal                         -15.9%    $30,540
Females
    Smokers
    Light                          -11.1%     $2,794
    Moderate                        -4.3%     $3,129
    Heavy                           -5.1%     $2,975
  Subtotal--Female Smokers          -6.6%     $8,899
  Excess Weight
    Overweight                     -28.4%     $4,757
    Obesity                        -26.0%     $7,766
  Subtotal--Female Excess Weight   -26.9%    $12,524
  Inactive                         -22.6%     $6,735
  Subtotal                         -18.8%    $28,158
Both Sexes
  Smokers
    Light                          -11.1%     $6,564
    Moderate                        -3.8%     $7,307
    Heavy                           -4.8%     $8,738
  Subtotal--Smokers                 -6.2%    $22,609
    Excess Weight
    Overweight                     -28.1%     $9,428
    Obesity                        -26.7%    $14,617
  Subtotal--Excess Weight          -27.3%    $24,045
  Inactive                         -21.7%    $12,045
  Total                            -17.3%    $58,698

                                   Variance   % Var.

Males
  Smokers
    Light                             $376    11.1%
    Moderate                          $131     3.2%
    Heavy                             $250     4.5%
  Subtotal--Male Smokers              $758     5.8%
  Excess Weight
    Overweight                        $898    23.8%
    Obese                           $1,445    26.7%
  Subtotal--Male Excess Weight      $2,343    25.5%
  Inactive                            $892    20.2%
  Subtotal                          $3,993    15.0%
Females
    Smokers
    Light                             $282    11.2%
    Moderate                          $128     4.3%
    Heavy                             $154     5.4%
  Subtotal--Female Smokers            $563     6.8%
  Excess Weight
    Overweight                      $1,008    26.9%
    Obesity                         $1,657    27.1%
  Subtotal--Female Excess Weight    $2,665    27.0%
  Inactive                          $1,164    20.9%
  Subtotal                          $4,392    18.5%
Both Sexes
  Smokers
    Light                             $658    11.1%
    Moderate                          $259     3.7%
    Heavy                             $404     4.8%
  Subtotal--Smokers                 $1,321     6.2%
    Excess Weight
    Overweight                      $1,906    25.3%
    Obesity                         $3,101    26.9%
  Subtotal--Excess Weight           $5,007    26.3%
  Inactive                          $2,057    20.6%
  Total                             $8,385    16.7%

RF = Risk factor; RR = Relative risk.

Figure 2. Estimated direct and indirect economic burden of
smoking, excess weight and physical inactivity, Canada, 2012
($000,000), adjusted for multiple risk factors in one individual

                            Smoking   Excess Weight   Physical
                                                      Inactivity

Indirect - S-T Disability   $1,963     $762             $243
Indirect - L-T Disability   $2,655     $7,349           $2,942
Indirect - Mortality        $9,695     $5,493           $3,803
Direct Cost                 $6,974     $5,433           $3,000

S-T = Short-term; L-T = Long-term.

Figure 3. Estimated direct and indirect economic burden of
smoking, excess weight and physical inactivity by disease
category, Canada, 2012 ($000,000), adjusted for multiple
risk factors in one individual

                            Cancers   Cardiovascular   Respiratory
                                      Diseases         Diseases

Indirect - S-T Disability   $119          $288           $1,896
Indirect - L-T Disability   $657          $3,587         $766
Indirect - Mortality        $7,257        $9,391         $1,281
Direct Cost                 $1,751        $7,761         $2,692

                            Diabetes   Musculoskeletal   Other
                                       Diseases

Indirect - S-T Disability     $48          $573           $45
Indirect - L-T Disability     $759         $7,145         $31
Indirect - Mortality          $942         $71            $50
Direct Cost                   $1,474       $1,502         $228

S-T = Short-term; L-T = Long-term.