The Economic Benefits of Risk Factor Reduction in Canada

The Economic Benefits of Risk Factor Reduction in Canada Tobacco Smoking, Excess Weight, Physical Inactivity and Alcohol Use Public Health 2015 May 26, 2015

Risk Factors in High-Income North America Ranked by Attributable Disease Burden 1. Tobacco smoking 2. Excess weight 3. High blood pressure 4. High blood sugar levels 5. Physical inactivity 6. Diet low in fruits 7. Alcohol use Attributable disease burden based on disability-adjusted life years (Source: Lim et al., The Lancet, December, 2012) 2

Can We Translate Disease Burden into Economic Burden? A major challenge is addressing multiple, overlapping risk factors in the same individual to avoid double-counting. 3

Overlap of Risk Factor Exposure in Canada Canadian Community Health Survey, Cycle 1.1 (2000) Ages 12+ Physical Inactivity 14.3% Excess Weight 19.4% 19.2% 6.3% 1.6% Smoking 4.3% 6.0% 1.2% Alcohol Use 1.1% 3.5% 0.9% 0.7% 0.7% 1.1% 1.0% No Risk Factors 18.9% Source: Adapted from Klein-Geltink et al., Chronic Diseases in Canada, 2006. Note: In this study, alcohol use is defined as "consuming more than 14.0 drinks per week (male) or 9.0 drinks per week (female)" 4

A Unique Economic Model That takes into account (and adjusts for) double-counting based on the overlap of multiple risk factors in any one individual (tobacco smoking, excess weight, physical inactivity and alcohol use). Krueger H, Williams D, Ready AE, Trenaman L, Turner D. Improved estimation of the health and economic burden of chronic disease risk factors in Manitoba, Canada. Chronic Diseases and Injuries in Canada. 2013; 33(4), 236-46. 5

Estimated Direct and Indirect Economic Burden of Smoking, Excess Weight and Physical Inactivity per Individual with the Risk Factor Canada, 2012 $6,000 Adjusted for Multiple Risk Factors in One Individual $5,000 Cost per Individual $4,000 $3,000 $2,000 $1,000 $0 Light Smoking Moderate Smoking Heavy Smoking Overweight Obesity Physical Inactivity Indirect - S-T Disability $209 $334 $466 $33 $86 $16 Indirect - L-T Disability $274 $466 $628 $324 $815 $189 Indirect - Mortality $1,008 $1,706 $2,279 $197 $698 $244 Direct Cost $727 $1,217 $1,648 $196 $689 $193 Krueger H, Turner D, Krueger J, Ready AE. The economic benefits of risk factor reduction in Canada: Tobacco smoking, excess weight and physical inactivity. Canadian Journal of Public Health. 2013;105:e69-78 6

Estimated Direct and Indirect Economic Burden of Smoking, Excess Weight and Physical Inactivity per Individual with the Risk Factor Canada, 2013 $6,000 Adjusted for Multiple Risk Factors in One Individual $5,000 Cost per Individual $4,000 $3,000 $2,000 $1,000 $0 Light Smoking Moderate Smoking Heavy Smoking Overweight Obesity Physical Inactivity Indirect - S-T Disability $199 $304 $411 $37 $94 $18 Indirect - L-T Disability $254 $449 $613 $383 $937 $226 Indirect - Mortality $847 $1,465 $1,979 $213 $731 $251 Direct Cost $669 $1,146 $1,560 $235 $794 $216 Krueger H, Krueger J, Koot J. Variation across Canada in the economic burden attributable to excess weight, tobacco smoking and physical inactivity. Canadian Journal of Public Health. In Press 7

$25,000 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 $20,000 $21.3 Billion $19.0 Billion Total Economic Burden: $50.3 Billion Total Cost ($000,000) $15,000 $10,000 $10.0 Billion $5,000 $0 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 Krueger H, Turner D, Krueger J, Ready AE. The economic benefits of risk factor reduction in Canada: Tobacco smoking, excess weight and physical inactivity. Canadian Journal of Public Health. 2013;105:e69-78 8

$25,000 Estimated Direct and Indirect Economic Burden of Smoking, Excess Weight and Physical Inactivity Canada, 2013 ($000,000) Adjusted for Multiple Risk Factors in One Individual $23.3 Billion $20,000 $18.7 Billion Total Economic Burden: $52.8 Billion Total Cost ($000,000) $15,000 $10,000 $10.8 Billion $5,000 $0 Smoking Excess Weight Physical Inactivity Indirect - S-T Disability $1,744 $912 $278 Indirect - L-T Disability $2,477 $9,218 $3,419 Indirect - Mortality $8,104 $6,288 $3,807 Direct Cost $6,376 $6,876 $3,273 Krueger H, Krueger J, Koot J. Variation across Canada in the economic burden attributable to excess weight, tobacco smoking and physical inactivity. Canadian Journal of Public Health. In Press 9

Projected Economic Burden in 2031 1% Annual Relative Reduction in Risk Factor Prevalence 10

$60,000 $58,000 Changes in Economic Burden of Smoking, Excess Weight and Physical Inactivity 1% Reduction in Risk Factor Prevalence Compared to No Reduction Canada, 2012-2031 (Constant Million$) $26.4 Billion Cumulative Reduction in Smoking Burden Reduction in annual economic burden of : $3.1 billion by 2031 Economic Burden (Million$) $56,000 $54,000 $52,000 $50,000 $20.3 Billion Cumulative Reduction in Physical Inactivity Burden $2.1 billion by 2031 $3.2 billion by 2031 $48,000 $46,000 $44,000 Fiscal Year 11

A 1% annual relative reduction in risk factor prevalence would lead to An $8.5 billion (14.3%) annual reduction in economic burden in 2031 12

Projected Economic Burden If all provinces achieved prevalence rates of the risk factors equivalent to those of the province with the lowest rates 13

Prevalence of Tobacco Smoking in Canada By Smoking Category and Province, 2012 25% 20% Proportion of the population who smoke 15% 10% 5% 0% BC AB SK MB ON QC NB NS PEI NL Province Heavy 20 cigarettes daily Moderate 10-19 cigarettes daily Light <10 cigarettes daily 14

Prevalence of Excess Weight in Canada By Excess Weight Category and Province, 2012 70% Proportion of the population with excess weight 60% 50% 40% 30% 20% 10% 0% BC AB SK MB ON QC NB NS PEI NL Province Obese Overweight 15

60% Prevalence of Physical Inactivity in Canada By Province, 2012 Proportion of the population who are physically inactive 50% 40% 30% 20% 10% 0% BC AB SK MB ON QC NB NS PEI NL Province 16

All provinces achieving age- and sex-specific prevalence rates the same as BC would lead to A $5.3 billion (10.0%) annual reduction in economic burden in Canada in 2013 17

Projected Economic Burden If all regions within BC achieved prevalence rates of the RFs equivalent to those of the region with the lowest rates 18

25% Prevalence of Tobacco Smoking in British Columbia By Smoking Category and Health Authority/HSDA, 2011-12 Proportion of the population who smoke 20% 15% 10% 5% 0% Region Heavy 20 cigarettes daily Moderate 10-19 cigarettes daily Light <10 cigarettes daily 19

60% Prevalence of Excess Weight in British Columbia By Excess Weight Category and Health Authority/HSDA, 2011-12 Proportion of the population with excess weight 50% 40% 30% 20% 10% 0% Region Obese Overweight 20

Prevalence of Physical Inactivity in British Columbia By Health Authority/HSDA, 2011-12 50% Proportion of the population who are inactive 40% 30% 20% 10% 0% Region 21

All regions within BC achieving age- and sex-specific prevalence rates similar to the region with the lowest rates would lead to A 24% annual reduction in economic burden in BC in 2013 22

Incorporating Alcohol 1. Defining drinking categories 2. Sources of exposure data 3. Adjusting for under-reporting 4. Sources of relative risk data 5. Harms/benefits associated with chronic alcohol consumption 6. Harms associated with binge drinking (accidents and injuries) 23

Prevalence of Alcohol Use in Canada By Sex, Age Group and Drinking Intensity 2012 Males - Category I (0.02-2.93 drinks/day) Males - Category II (2.94-4.40 drinks/day) Males - Category III ( 4.41 drinks/day) 100% 90% Females - Category I (0.02-1.46 drinks/day) Females - Category II (1.47-2.93 drinks/day) Females - Category III ( 2.94 drinks/day) Proportion of the Population 80% 70% 60% 50% 40% 30% 20% 10% 0% 15-29 30-44 45-59 60-69 70-79 80+ Age Group 24

100% Prevalence of Binge Drinking in Canada By Sex and Age Group 2012 Males - Non-Binge Drinkers Males - Binge Drinkers Females - Non-Binge Drinkers Females - Binge Drinkers 90% Proportion of the Population 80% 70% 60% 50% 40% 30% 20% 10% 0% 15-29 30-44 45-59 60-69 70-79 80+ Age Group 25

$6,000 Estimated Direct and Indirect Economic Burden of Smoking, Excess Weight, Physical Inactivity and Alcohol per Individual with the Risk Factor Canada, 2013 Adjusted for Multiple Risk Factors in One Individual $5,000 Cost per Individual $4,000 $3,000 $2,000 $1,000 $0 Light Smoking Moderate Smoking Heavy Smoking Overweight Obesity Physical Inactivity Low Alcohol Use Hazardous Alcohol Use Harmful Alcohol Use Indirect - S-T Disability $207 $315 $427 $38 $97 $60 $19 $120 $253 Indirect - L-T Disability $265 $466 $639 $392 $964 $108 $27 $186 $589 Indirect - Mortality $890 $1,535 $2,083 $221 $759 $304 $103 $545 $1,336 Direct Cost $705 $1,199 $1,638 $240 $817 $203 $59 $398 $1,223 Krueger et al. The economic burden attributable to excess weight, tobacco smoking, physical inactivity and alcohol use in Canada. (Forthcoming) 26

$25,000 $20,000 Estimated Direct and Indirect Economic Burden of Smoking, Excess Weight, Physical Inactivity and Alcohol Use Canada, 2013 ($000,000) Adjusted for Multiple Risk Factors in One Individual $19.8 Billion $23.9 Billion Total Economic Burden: $63.9 Billion Total Cost ($000,000) $15,000 $10,000 $9.5 Billion $10.7 Billion $5,000 $0 Smoking Excess Weight Physical Inactivity Alcohol Indirect - S-T Disability $1,833 $931 $182 $913 Indirect - L-T Disability $2,609 $9,431 $2,208 $1,654 Indirect - Mortality $8,603 $6,491 $3,967 $4,664 Direct Cost $6,763 $7,018 $3,106 $3,503 Krueger et al. The economic burden attributable to excess weight, tobacco smoking, physical inactivity and alcohol use in Canada. (Forthcoming) 27

$25,000 $20,000 Estimated Direct and Indirect Economic Burden of Smoking, Excess Weight, Physical Inactivity and Alcohol Use Canada, 2013 ($000,000) Adjusted for Multiple Risk Factors in One Individual $20.0 Billion $24.1 Billion Total Economic Burden: $62.0 Billion Total Cost ($000,000) $15,000 $10,000 $9.6 Billion Assume a protective effect with low, non-binge alcohol consumption $8.4 Billion $5,000 $0 Smoking Excess Weight Physical Inactivity Alcohol Indirect - S-T Disability $1,851 $941 $183 $886 Indirect - L-T Disability $2,635 $9,524 $2,230 $1,205 Indirect - Mortality $8,688 $6,555 $4,006 $3,701 Direct Cost $6,830 $7,087 $3,137 $2,561 Krueger et al. The economic burden attributable to excess weight, tobacco smoking, physical inactivity and alcohol use in Canada. (Forthcoming) 28

Future Work Model the economic benefits of reducing alcohol use Model the economic impact of changing RF prevalence from 2000 to 2013 Building a computer application 29

60% Prevalence of Risk Factors Canada, 2000 50% Harmful Hazardous Prevalence 40% 30% Obesity 20% 10% Heavy Moderate Overweight Low 0% Light Tobacco Smoking Excess Weight Physical Inactivity Alcohol Use

60% Prevalence of Risk Factors Canada, 2001 50% Harmful Hazardous Prevalence 40% 30% Obesity 20% 10% Heavy Moderate Overweight Low 0% Light Tobacco Smoking Excess Weight Physical Inactivity Alcohol Use 31

60% Prevalence of Risk Factors Canada, 2002 50% Harmful Hazardous Prevalence 40% 30% Obesity 20% Heavy Overweight Low 10% Moderate Light 0% Tobacco Smoking Excess Weight Physical Inactivity Alcohol Use 32

60% Prevalence of Risk Factors Canada, 2003 50% Harmful Hazardous Prevalence 40% 30% Obesity 20% 10% Heavy Moderate Overweight Low Light 0% Tobacco Smoking Excess Weight Physical Inactivity Alcohol Use 33

60% Prevalence of Risk Factors Canada, 2004 50% Harmful Hazardous Prevalence 40% 30% Obesity 20% Low Heavy Overweight 10% Moderate Light 0% Tobacco Smoking Excess Weight Physical Inactivity Alcohol Use 34

60% Prevalence of Risk Factors Canada, 2005 50% Harmful Hazardous Prevalence 40% 30% Obesity 20% Low Heavy Overweight 10% Moderate Light 0% Tobacco Smoking Excess Weight Physical Inactivity Alcohol Use 35

60% Prevalence of Risk Factors Canada, 2006 50% Harmful Hazardous Prevalence 40% 30% Obesity 20% Low Heavy Overweight 10% Moderate Light 0% Tobacco Smoking Excess Weight Physical Inactivity Alcohol Use 36

60% Prevalence of Risk Factors Canada, 2007 50% Harmful Hazardous 40% Obesity Prevalence 30% 20% Low Heavy Overweight 10% Moderate Light 0% Tobacco Smoking Excess Weight Physical Inactivity Alcohol Use 37

60% Prevalence of Risk Factors Canada, 2008 50% Harmful Hazardous 40% Obesity Prevalence 30% 20% Low Heavy Overweight 10% Moderate Light 0% Tobacco Smoking Excess Weight Physical Inactivity Alcohol Use 38

60% Prevalence of Risk Factors Canada, 2009 50% Harmful Hazardous 40% Obesity Prevalence 30% 20% Low Heavy Overweight 10% Moderate Light 0% Tobacco Smoking Excess Weight Physical Inactivity Alcohol Use 39

60% Prevalence of Risk Factors Canada, 2010 50% Harmful Hazardous 40% Obesity Prevalence 30% 20% Low Heavy Overweight 10% Moderate Light 0% Tobacco Smoking Excess Weight Physical Inactivity Alcohol Use 40

60% Prevalence of Risk Factors Canada, 2011 50% Harmful Hazardous Prevalence 40% 30% Obesity 20% Low Heavy Overweight 10% Moderate Light 0% Tobacco Smoking Excess Weight Physical Inactivity Alcohol Use 41

60% Prevalence of Risk Factors Canada, 2012 50% Harmful Hazardous 40% Obesity Prevalence 30% 20% Low Heavy Overweight 10% Moderate Light 0% Tobacco Smoking Excess Weight Physical Inactivity Alcohol Use 42

60% Prevalence of Risk Factors Canada, 2013 50% Harmful Hazardous 40% Obesity Prevalence 30% 20% Low Heavy Overweight 10% Moderate Light 0% Tobacco Smoking Excess Weight Physical Inactivity Alcohol Use 43

60% Prevalence of Risk Factors Canada, 2000 50% Harmful Hazardous Prevalence 40% 30% Obesity 20% 10% Heavy Moderate Overweight Low 0% Light Tobacco Smoking Excess Weight Physical Inactivity Alcohol Use

60% Prevalence of Risk Factors Canada, 2013 50% Harmful Hazardous 40% Obesity Prevalence 30% 20% Low Heavy Overweight 10% Moderate Light 0% Tobacco Smoking Excess Weight Physical Inactivity Alcohol Use 45

Future Work 46

Future Work 47

Comments / Questions? 48