Discussion

Hospital care costs were 1600 Euros greater per person year for living individuals among smokers during the follow-up, but due to a 8.6 year shorter lifespan, the total costs per individual were 4700 Euros lower among smokers than non-smokers during the entire study period. This study provides the first evidence of the net economic effect of smoking versus non-smoking on costs related to health and social welfare, based on prospective, individual level data.

Smoking resulted in a moderate decrease in the productive occupational career and income taxes and pension fees paid, a moderate decrease in healthcare costs and a marked decrease in the pension costs. The costs of smoking to society have been modelled by using estimates on increased mortality and morbidity.6–18 However, none of these modelling studies investigated the overall net economic effect of smoking on public finance balance by using actual data from individuals, and only a few had taken into account all the following factors; lifetime productivity or income taxes and pension fees paid, pension costs, and a monetary value of life years lost.17 ,18 Our results indicate that combined, these factors make a considerable contribution to the overall net effect than merely healthcare costs which is in line with the modelling studies by Sloan et al17 and Viscosi.18 If the potential increase in quality adjusted life years is taken into account, our results suggest that the life long net beneficial economic effect of early smoking cessation is more than €70 000 per individual, and this sum did not change substantially when propensity score was applied in the analysis. Our results also indicate that reducing the rate of smoking has a huge beneficial economic effect on society, mainly due to increased lifespan and continued pension costs. In Finland, the National Institute for Health and Welfare aims to make Finland free of smoking by the year 2040. Since there are currently about 900 000 smokers in Finland, the average net effect of €134 000 per individual on public finance balance (without taking into account the monetary value of life years lost) would correspond during the next decades to about 120 billion Euros total increase in costs (over 2.5-fold to annual state budget). However, this nominal deficit would be massively outweighed by about 2 years increase in life expectancy of the whole nation.

Our overall results on the net economic effect of smoking on public finance balance are contrary to the Philip Morris report. A major reason for this difference is that Little did not consider the inherent value of the quality adjusted life years lost. In other words, if we used an estimate of 0 Euros for each lost year of human life, then the positive economic effect of smoking in our study would have been even larger than the effect estimated by Little. However, when considering the implications of these results, the major question is whether or not humans are to be valued as commodities, like domesticated animals, or does human life maintain an inherent value even when the individual is no longer economically productive, as in retirement? In the field of healthcare, it is generally assumed that all human life—even that of the old and disabled—is precious and has value. This view is also currently accepted by national authorities throughout most of the modern world. Already in 1999, 387 billion USD was used in the US for medical treatment and care of people older than 65 years.30 Nowadays, it is generally agreed that the monetary value of one additional life year of a healthy human being is about 20 000–30 000 British Pounds when additional costs of medical care are considered.27 One may ask why societies continue to invest even larger amounts of money and other social resources to achieve a longer mean lifespan for citizens, when a more drastic increase could be achieved administratively, without any further costs, by substantially raising tobacco taxes and otherwise restricting access to smoking? There are two likely answers: either governmental authorities have not realised this fact, or they have realised it, but do not want to increase life expectancy due to a subsequent increase in healthcare and pension costs.

While denying access to medical care for older people, in order to prevent a deficit in the national economy, would not be possible because of common ethical concerns and public opinion, preventing a decrease in smoking rates essentially has the same effect, and is apparently more acceptable to many societies. If this is the case, it would also explain the reluctance of governments to regulate eating and other consumption habits that negatively affect the general population by, for example, increasing the value added tax (VAT) on food products that are high in sugar and saturated fats, and decreasing VAT on fruits and vegetables, for example. The Czech prime minister stated in 2001 that smoking is beneficial for the state, because smokers die sooner.17 ,18 Such comments have not been echoed by other state leaders; however, it is possible that this view still influences tobacco policies in many modern countries. Therefore, governments should be transparent concerning which kind of knowledge their tobacco and food taxation policy is based on. Our study cannot answer the question on why cigarette taxes are still low in many countries. Therefore, this remains open and a topic for further research.

The strength of this study is based on empirical data that were gathered from a 27-year prospective study. Thus, no assumptions on healthcare, pension costs or discount percentages of future costs were needed. One shortcoming is that this study did not include women, and it did not include visits to general practitioners, home nursing or medication and dental care costs in outpatient care, which contribute to about 20–30% of the total healthcare costs among elderly and middle-aged people in Finland.25 In a previous 19-year follow-up study, it was observed that although the overall healthcare costs were higher among smokers aged 25–59 years, the costs of medication in outpatient care did not differ between smokers and non-smokers.31 Thus, it can be further estimated that the total healthcare costs might have been at the most about 6000 to 7000 Euros higher per individual among non-smokers when compared with smokers, instead of our modest estimate of about 5000 Euros per individual. However, the magnitude of this difference (€ 1000–2000) is less than 2% of the pension costs, and does not have any substantial effect on these results. We also did not include the costs of fires or littering related to smoking, as this information was not available, yet the combined contribution of these factors is probably less than 1% of the total costs.12 Since only 17% of the initiated subjects refused to participate, the generalisability of the results can be considered quite sufficient.

It was presumed that smokers’ lower education level and lower income level were not caused by smoking, and that differences in these characteristics were associated with smoking due to the fact that less educated individuals are more likely to start smoking than individuals with a higher educational level. Therefore, it was assumed that smoking cessation would not substantially increase education level or income. It can be estimated that during a productive career of about 35 years, with an annual difference of € 2970 in paid income taxes, smokers in our study have paid an average of about 100 000 Euros less income taxes than non-smokers. If it were assumed that early smoking cessation would change these variables to the same levels as with non-smokers, the net difference between smokers versus non-smokers would shift from €134 000 to about €30 000 in favour of smoking, if the value of life years lost are not included, and from €70 000 to about €170 000 in favour of non-smoking if the value of life years lost are included in the analysis. Either way, the principal conclusions on the net costs would remain the same. It is questionable if tobacco taxes should be considered as beneficial increases in income to the state. For example, if an individual would not have been smoking, then he/she probably would have consumed more goods in the extra years of life and thus paid more taxes for those goods instead of the taxes paid for cigarettes. Overall, the estimate of a €70 000 beneficial effect of early smoking cessation per individual is probably an underestimate.