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i AET, EIIDLY' F NEW YORK CITY: SMOlCING-ATTRIBUTABLE MORTALITY, MORBIDITY AND ECONOMIC COSTS Prepared' by: James M. Shul tz „ M. S. Mi'nnesots Department of Health Minneapol is,, Minnesota May, 1986

1.40 INTRODUCTION 1.1!0' SMOK'.I'NGrA'TTRIBUTiABL.E MORTALITY . Csya~;at.`_2 smckiny' is the chief, sinqle pre•.entable 'cause of death in the l'Jni tzd States. A seri es of Surgzon GeneraL '_. Repcrts on smoking and health has implicated cigarette' smo4::ing as a principal cause of death of 'S0.0c.i0Americ_n- each year. This fiy,ure rep:re=_ents the sum of e=_timate= c:f smok:irng7athributab:le mortality from heart disease--1,0,000 deaths (USDHHS, 1980, cancErs of murl ti p1'e sites--1'0, 0-~i deaths (USDHHS, 19SC), and chromic obstructive lung dis_ase--50,,ri00 decths !'tJSDHHG„ 1984') . Recent e:stimates have pL acad' •annaial nati onal deaths f rom smok: i ng at 314,000 (Dffi'.c.e of Technology Assessment, 1985a) and 270.000 (F:ice. Hodqson„ Sinsheimer„ and Ecrowner, 1985). respectively. 1.20 HEALTH ECONOMICS AND EP'IDEMI!OLOI6Y' The ca'Tculation of "costs of iilness" has been reFined a'nd' aystemat:ced during the last two decadles. This endeavor. drterm'ininq'the costs of all diseases in the aggregate. dzterminlnq, the-costs of major categories of diseases (canccrs, h,Part disease), andl determi'ning costs of d'isease_ by primary cost sources (hospitals'~ phy_ician fees, nur_in,- home co4tsJ has app.ropriateTy residedl a~ithin the purviie"-~f heel th ecQnomi cs'. F'r-imaril y wi'thi'n the last decade, several attempts ha•.e bwen made to translate the health toll from cigarette =_mckinq :nt_o economic cost estimates. Calcul ation of the cost:s o:f _m.o!•.ing requires brid'qi'ng across the disciplines or health economics and epidemiolog;.°. This merger of ev:pertise is necessary to define causal 1inb.ages brtwc:en =_moi!ing and multiple diseases, and-t` provide quantitative estimctG= of theproportions of disease cases attributable to smohi;ng.. 1.30 COMPUTER' SOFTWA'RE FOR MORTALITY, MORBIDITY, ANIDi ECONOMIC COST CALCULAT IDNS 5af:ni.ny the dliaease impact of smoking for the group under study can be f'aci 1 i tated b•: appl yi ng state-of-thc--art p.aN,aqyd for ease of use byy heal th prorassionais:. Computer spreadsheets used for New Citv 3.'c'.t l±t. l•1'n' s hd.y been dE:`+'t`31 opFed at the ML (?1'nE?si7t,a De,''Jor t,iT.-r" t ,,,4 ' I-;eal th Qhu1. tc , 198341 whTcfi compute sToPi ny-spec i f. c 85648422

disease i,:Tp;_tLt, incRsl_Fe.' reca11i;1 u'Fijat,ad b`.~` Rice and colleaaucs CF:xce„ Hc:;dy :on', Sir7sheimer, rind Bro:,,rer, ±JST,. 2'. 00-.NEW YORK CITY: SMOKING-ATTRIBUTABLE MORTALITY CiT`ulation of smo4:inq-attributable mortality requires nP definiti!on cf the set of diaqnoses causally linledto .ci.garettz smoking,,, i_) an estimate of the relati .e r:>!-: ronr siTloke.rs coillpared to nonsmokers for e~c;h d'idglnosis, ard ' !7; inf ormwa't ion on smick ; nq' prevaT emce rates. Lorrent smokers are at increased risk for muLtiple dices=_=, primari ly from three dliaynostic cateqories: neoplasms„ respiratory d.iseases, and', cardiovascuolar di=_ea=_es. Fcrmer s„:okars are al so at el evated ri sk compared to never smoE er-, for a period of time po=_t-cessation. That time period varies by di:agma5is and by level of lifetime tob'acco smoE>:e. enwosure. Data from several 1arge prospective epidemiologic studias whi'ch e;ramirrined' the impact of smoking on multipl'ee d'iseasz outcomes permit estimation of relative ri=_l.s for both current and former smokers for approa: i matel y Cfi d'iagno=_es. c^.1CQ THE DIAGNOSIS SET The drzA3nasrs set u'sedl f'or New York Ci ty caLcul ations 1 s identicc,l to that used by Rice, Hodgson, Sinsheimer, cnd' Browner ('1955) .- Earl i er stud i es have i ncl ud'ed addii t i on all smoE:inng-r'elated'~ diaqncases (Rice and Hodqson, 19S7; MD'H. T%4) . The diagnosi=_ set used. by F;i'ce and colleaqucs r_s generally distinquished by robust relative risk estimate-, typ.ically derived from"inulti'ple prospective stad'ies. The folTowinq, diagnoses are inc1!udzdl in"the campuntations: ICD-9 C d no Di is o e 1*1l ;i-<~1C ag s F'espiratory tuber'c'uI'osi s. 1 4 Ci -14!9 Cancers of the L i p, oral cavi ty, phar,;n~: 1 !~%'? Cancer of' the esnphayus 151 Cancer of the stomach 157 C.nnc'er of the pancreas m' 161 Cancer of the 1ar vn:: tJT Cancer s of the-1 unq, trache a, bronc_nus ~, 1 J'( / Cancer of' the uterine cervl:: ~ ~9N9, Cancer of the kidney W' Ah .' ~'. Qa~ .:

C Hypertc+is ion _ tsche:n'ic heart disea5e C'ardiac arrest Carabro.rescular d'ise~~se AtfieroslIerosi s Aortic aneurysm 4?~u-4W 7' F'neumoni a; i nf Z uen: a 4?1-4!aC Chronic bronchitis, emph>/se,ra 4!95 Chronic ai'rways ob=tructi'on~ 5 71 1-C'4 Ul cers The e::'clusion of' liver cirrhosis (appearing in e:~rlier7 iss r'e-asonabl!a because of' the strong, covar'iation ,f and aicoha1l c(Jr'i5UiTlptYon. Other dliagniJses, T1asV iTe'rlt, inclusioni in f'utur'e calculations. Peripheral vascular disease (ICD-9 Code: 44.C) appears to have a stronq 1l1nG: to smoking (USDHHS, 190-') but reZati~xe r'is4:: estimates are generally: 1'ack:ingi. Attributabl'e risks have rerFntly been estimated for per'i'natal and early childhood' cnnditions l i nE: ed to maternal smoG~i ng (Mc Iintosh, 198'4 ). Di aynosEs to consider for inclusion are: short gestation andilow birth weight (ICD~9 C,3(Je: 7-,:r), respir'story di's'tresss s•;zndrcme ('I1CD-9 Code: 76?) , re=_p i ratory cond'i t'i ons of the ne~jt,orn Code: 7'70), and suddP-n infant death svndrome ~'IC'C-'= Code: 792.!:}) . Cor7,.ersel;:, hypertension iis i~ncPuded by Rice end coPlea,;-;es . bPcause of modest relative risks in several major stuid:es. Hbwever, the 1acE:: of consi'Stant e-vidence for a cau=_ai relationship between smok:i'na and hypertension was noted in the 19S'_• Surgeon Gereral "s Report (USDHHS, 19s') . That report did concede a'possiblv causal relationship between s,nol,: ing arrdi ear ly stroke (pri or to ape, -55) . The R;'i d'a, et al'. , methodbloy,y includes all ages in calcuIlaticns o+ sm'oking-attri!butabl'e' czrebrova=_cuTar diseases. Finallyr„ chronic airways obstruction (ICD-9' Code: 496 + :•,a-- incliuded' i'n addition to emphysema and' chroni_c bronchi:ti=. In Minnesata„ and presumably elsewhere, when a patient presents with chronic obstruct.ive Zung disease (CDLZ% symptoms, the physician may attempt' a d'iff'erential diagnosis to classiify the patient as havingchronlic bronchlitils or emph•fsema.. Very of ten, the case i s not easi l'y cl assi f' i ed into one of these categories and' is classified instead a=_ r_hron tc airways obstruction. W 2.20 ' RELATT VE R I SI` EST IMA'TES C11 . . ~

!r ~`r e'ach' dl 7g r, 0-s 1' =_ 1'n th P_ =a1cu, la tl~7ns't rZla '-_ 1•ia' irl SI estimates are a,Iailablr fr-om major lenigitUdinal epldem.e-' 1ogilc StUdl'es and' these estimates are th'cr-7l.(yhl : in a series of four Surgeon General's Reports !UEDHE'uJ, 13'',; USDHHS, 199C': USrJHHS, 199''; USDI-IHS, 19°4) . 1'ni previ'cus wor:. iF:it_e and Hcdgson, 198__;, MDH, 1984) relative ris4:s u(sea were d1:3',,:,G or T1ed1.3n vdil.leS from' si_lmmar/ tables app',.?_arI!'iq ' ..:. report?s cf ttie Surg,eoni General. In the Upolat.ed wC;i-:: •_ F'ice. Hodyi>>n,i Sinsheimer, and Browrner t t Mr; , rr: l4+ ,.';~ risks for each diagnosis are .actlny: 'i Accardingto the meth:~t ~ ;,;_,_ . L car, • ( epu.,r t , ~,~. L.~_1'ijl L: '~. ~1a7~_. 1..~~~'~~}' «ai~l lIlc?. :. i..~, -. ~ _.~. ~~ fi _. 1~-... -..`~.rc-' -.' . _,. ~ Jht la'iJ~ ......, .~ + ~ .~~.1_.. T:i:: ,'Lri:a 'L :3e1-;rl-'r --l:e?c ~ ". _ ~ - . . . .' ,.,': P ., ._., •"..' , _ _~: . ^.I ....j• C:r~ ! ~.1 ~-a!"t. F-'h.`, :Sli~=1..a~1"i'- =f~.~~a.t_~~'i., 1:-Pj "t_-Llt::, 1jr; t.Cd' ..i : r,rm r:S4Cs f,.;r- fT JL a"j-:I1,J5i:S we;r~?' f,7r c_,-.eIlh. ,:al ~ _- ~ EW `i~t7F.'F' C 1 T'' . 1 `~94 ": EW4 tb -..-3':~~.i .,h ~ r 2:, JC?:At'h,s yimony nan s ni_74 er-s J.i..'7 t, t.,. _aIm-yaars of observation in stuld~r i person-years for smokers in StUid•.. i person-years -for nonsmo4::ers in studyi 2.30 SMOKING PR'EVALENCE' RATES. Smoking, preva'lence rates usedl in the spreadsheet calculations are 1984 New York: Cit, , rates based an projection of' large sample data to the entire popu:ation r=t New York City. These numeric and' percentage zstimat=s or cc:crrent, former, and ne•:•er 3mo4:ers were calculated b•,• ,:ip:d'emiol'ogists at the New York City Diepartment of Hralth. ' - ' T,b.a~ _.'H. SMQF ING F EE .'ALENCE F:MTES "1A LF_8: a''-_4 2 5 -_4' 7 5 -4 4 45 -6 4 ~~+ ~',

;:,JF:FEVT . 6 5 '. 7'1.5~.. 'O W=,. ii.'S7.: 21.15. FORMER . e.67 -O. 08 :. 21. 17 26.71 40.75 NEVER 5;'.68 42.22 34.00~~4'. 1C 78. W _ ' . , ^i ~ '. . T ~ ^ _. .. .... ~ ~. ~~ ~ ~ : ' FEMC,LES _ - ~4 - 4 . .J J~`t '7" ~v; ~ '7..J''t 6W . CUF:F'EhiT 26.62% =3.'u?;'. _. 16;. Em.27% 1 a'.W: FORMER 12494 11,51 M I6.54 1b.?6 22. 4' NEVER 60. 44l 54. 8C' 50. 20 51. -7 6'.7"' . 2. 4'O ATTR I BUTABG.E R ISY< CA4.CULAT IDN The critical cal!cuTation in this spreadlsheet is the smokiny- attributable fr.,cticn of deaths from each smoking-related dia.gnosis. The attributab1'e ri5l: calculation manipulatcs the data elzmenf s di scussedl above; for each di agnosi s in the diag;nosis set, the gender-specific smo~~!;ing-attri5atable risl:: i s calicuTated from currant, former„ and never smcker prevaLence rates and from current and' former smcG er rei''ati fe risl;s according Wthe following formula: CpO +p 1( RR 1) + Q 4RR'_')7- I Httributab1!e F:i sk = ---------------- ----- Cpca' + p1 (F:R1) + pZ'CRR2) 7 where: p!'i: - percent of never smokers in group under stud-i p l: percent of' current smok ers i n group under =_tud'/ p2': '- per-cent of former smokers in group under st+_id, RR2: • weiyhted relative risk for former smokers* . RF'1: weighted relative risk for current .smckerst * rel ative to never smoE! er=_ 2'.60 DA'TA SUMMARY Tab l e r^..6r+: ANNUAL SMOFr.:I'NG-ATTFi I L+<UTF',BLE "1OFi'TAL I,T`+ roEW YORY CITY . m AGE GF:GUF' MALES FEMALES FOTN' SEYEJ ~ ~ 20-a- 7294 1954 112 4 3

ZO:-'44 48` 177 :5' 45-64 ., 897 l.=u5--' .-. • 3.' 1 4~J.•.,7~ 2.50 SUMMAFeY OF METHODS i+rom g:nder-spec't f lc siToki,ngprt-"6val,enice rat,r=5 f(or =orr -'o" and former =_mokers ('for al L ages _0-and over, for a,;e 0- - 6F, and far aqes 6C-and over) and gendcr-spar_i f u<< mor ta1 t`. data for C0' d'iagnoses, es.timates of s!moGrinq"attrtbutabl _ rort a1 i t.y wern computed for mal es, fema'1 ts, and both :,emAr= 7E b: i ndli •, i dua'1 ddagross s, by d i agnost i c cat:egory, and f or the t,_t,aii dii,,,gnov:s sYt. The numbersof deaths are presente.d tn ?y'e b'.racE, ets: : 0-441„ 4'5-54, 6C-74, of these bracr:e'ts, a'ges 2~~:> and over., 75 andi over 3.00: NEWYORkC CI?Y: Sf9OK'IN6-ATTR'IBUTABLE . YEARS OF'POTEN'TIAL LIFE'LOST (YPLL) 3.10 METHOD'OLOCiY' AND SOFTWARE OPERATI'ON'. tssi~_~e's inuolved in the cal'cul ation of _nok:.nq-autributa'b1e mortality are' g,ermane to the .:a'1zur: xtion' of years of potential 1'ife lost. hi._..-i7t .. .Ji.i se~nC.e Wll-1w 1995s. I,1~9~O..cJb~.J'~. Havi^g d!ef'ined the diagnos'is set of diseases cauu_aI1v 1tnl=t to sanoking, and ha4ing inserted the two comp'on?n* .:ar:;tlps of the attributable ris1: formula--smoF:_ing p,~reval:ence, rat__ and gender and d i seaye-spe'c &ic, wce,i ghted'. rel at i4n r i=', est'imates--smoking-attributablr mortality ha'= been cal''culated4 Cigaret te smok i ng i s tCnown to ca!_~Ja' nr~m :r _:=e mortali ty i n the sense that nonsmoker=_ are 1 ess L:. Wel , t.= dl e f'rom certal n s+To4: i ng-rCl at'zd diseases and ntilnsilrihet' _. "; .:; do succumb to thes= di ag'noses yeneral l y d'i e at amor-_ e-. .;d r-;nced age than th'ra.~i r coun terp<art s who amoke. Hawe', re1ative ris1:; data' bu a:aa isy only a•.nailable for a.mal 11 na,nber <<f :dia'ynose_. Estima:ti'on of e:;cas=_ smoking-- ,ttl.rt ib~':;t.abte mcrtaliity by age of' death has been perfvr,ra.-' f'c,r r_;rrcer-= c_~f sa:era'1' s'ites (Coll and F'etW. 1TE'Li', for Lsclhow.c heart disasse !^1DH, 1184), and for botlh cacaer _ :' lJ,(',`~ ,1f RtL~O ar,~d~ n~a'.l.l.r.~.6ig'l-Dn^3 1~1?35i, d~:.di, rYG1t, osr3 nCl.o.- :p<-VIc y.c re::at7..C' "l si> data (a?;.Sept fur- t'wio, alE rang•_-

C a.hy.a 1 i ed~d t..i7 i.si=.h~aiG~1, -., h~ _ .. - _. : . _.- _ _:c3~, . 0. - sd annd 6J+I 1 . 4~~1 t..^.=. yasis for the skra..d _nart „+.h„-drL<_qw, the' wcr'k of h-hE=_. ~LinVestity.ytCr'a c_.n i.,•? _. ..:_yd to undc?'"ast1,^=t^a YPLL,. .`.c l iimif:,lng a'ssu!amF't ionl-1!S t;'+at, for each SiT,(DkLny-;^'e,.I at=6 d!lngnos'17, tirlre smWE:ing-,3tF_r.:,b'ut•3bl,e fr'.y,i=tlon r7f ijeatfis.[ s dii=_tri'biited_ in e;:act prapm_rtion to the di stribution cf al i~ d.=_ .,th.s Fr- ..m that cause. Th iazverrtuates a consar : at i._ e,;timnaa' of Y'PLL •based on the' prc_iumption of a di ..prroN'mr}i ]nate amount of earU':' death from"s,nokTngi. rates for r_urr?nt and f,orrner smoE:ar-, and aye and yendo.- - sFeci f l c mortaL i t}; data fcr thE' dl agnes:. s set--chE: -:=r'?a1sheet s[7ft.Wctr-n interlial'1'y' ca1L:l.llatrr_'s siTlokinqattribatable mc,rta;:ity f'or males and females' bl rndi . Z_r_.1. di3".1'UzI','s.. Re5.1.(jc?nt .. l,nthiespr-andshe.e'tn are tC1b.l,es .. ot' ,<ptcted years of' iifa remainin'y for males and f'erri;les b. 5- y••,.r age', •jroUp. F'.r each d2'aLqnosl s, tCr' e'aCh' c-year a'yc groufa, the software multipli'es the number of deaths in thw aNl t b;. the :exprzcted years of I i f'e rem,,i niny for that age Jf d'e.'ath, and mul tipl i es thi s product, in turn, by the smo4: ing- afi.t.ributable risk for the d'iagno=_is. YPLL estimates are aqgregated into four age brracke}':.; 20-44, 45-641„ 6C-74, 70 .A rrd1 o•:.er. These age br<_,chet.s are summed to pro~ide the estimate of totall smoking-attiributable YF'LL for- each Using f'Jew Yurk City data--gender-specific smuki'ng pre•:a di.aynosi's. The spreadsheet provi des gender-speci f i r_ `rF'LL e'sti mate _.~or thQse age brackets by individual diagnosis nndl 5-> diay zstic crateg¢,ry. and' dlspllys total smcF:lng-attribUtable YPLL. Fur: -ha_rmore', these data ?.re al3o pr,-sen'ted tor bcrhisr ez- combinrd.. Additronai't f, all data-is computed' baaedl on twoo e`_s w'f nati'onal ye-zr=.-o'f-e>:p'ected-life-remaini'ng data MCH.:, 10''34'1 re'siid'ent in the spreadsheet: all races cr_anbi'ned and' whites. 3.20 DATA' SUMMA'RY ''ab~1 e 1~~.CAz ANNUAL SMDKI NG-H~TMI SUTM~LE~. 1"EraRS' QF' F'OTE"1TINL LIFE LOST (`rPLL)' F:ELAT I VE TO EXPECTED YEAF:S OF LIFE FE"'?!5L;;!_: New `!'crG:. Cvty (IifE' e;:p:ectancy for all r,___: AGE C;FOUF f1A LES FEt1ALES ' RQTH '_ E'! E' ; _ 9`* 111_5C b:4o5 ' 1,'=71-" _>,: ~ -4 4 1,_~r_,._ , . 4.a--'a.1 J1P/4 ~. - i 7?~. ~.~. _.'t~J'4 ` CV7 14M.,

4.00 NEWYORK CITh':' SMOKIh1IGr-ATTR'IHU'TAEtLE DIRECT HEALTH CARE COSTS 4.1C1 DIRECT COSTS' :rjl~u}: ing-<ittv i',:;Lttablt-~ direi_t c7sts ira ~r,u]_`._., __ ?,... th,e , ,?:.1.o^'',, d'.i.3g inus .1.° anld t:rC?a ,t'i71en1"_ ~f S7ic.r! ;i y-..:..._ _-_.. ~1~:da~=~l ~llll iT?GLi=a1 condltlloris., r'1,11'e:•_'_ l ~D`:>It._= inedi~.= al c=.'i'e^-per'sonai'; l1e;.~1,tj-i, :` lln .1~_lr~I'ry sUch c17st t=t='nt.e?rz _irs hGSpltct.lTze,tlGn,, SlLtr~c~tL=~i}' L1in'Tc-=i1 care?, nttr'siny' hiome cc7re, home health c-;r_., ser:ic~~ ro+ prlmarv ph, sic.ilans and': jpecial ist:s, servic;~~ of non- p'hysici•an h,,al1th practitioner-s, and medl =atiorr co=_ts., ,?Lrrect costs al'.sn inctt_tde the "St_spport" costs o+ proaram a.d;ni^isrration, resear'ch, public he'aTth acti:rtie~, and maaiir_al f,~tt_i l ities constrt_iction costs, a...riie;- =_''_tdi:es ap!plked the "mortali'ty ,_'cmparlson" tA3f:1hi:db1'oM3'f lL!:Ce dn'tr' jL.t`lwelt.'.er, 1977; F';1't=e and Hr;d4,s''._„-. which as=_umed that the proportion u+ attr iL-1_ttab ae ;ncrt•a'1 it f fur 1' aryz dise;,se grrurp.=_ ,~.- a arc::•;y tor esti.matiny the proportron of smaL. Ln~ ~it;~ rlbi_t} - afl'i r3' t~:~~t.'~,. i i re rCi=trnt.) y ~_Lpt~r ~ded' m~?t!z ;i;ci ~,~'. =r ~'1~i:~; an d' CJ11?,agU.ts s :19SJ)' applLa~ dlrect' me_is1jrc_ :at di~f~?r er~tia'1 medical care t_ttili-ation by cur;^'ant ard ._,n•.~Eers relative to never smokers. ' MeCica1 uti1l~~,ti.cn h, a~nc4. in•a st?:tt!rs was obtairred from speci al anal .se= o+ t1~Lii.~n~.T Heal'th Int'er•~iew Si_tre^a erf data. The met`Icd ent,lla =.tzps, (1) Di fferences be+:wken smol ;Ar=_ and ne•,-er smc~ ar ; 1 n capita rates of' ut'11 ilzation of hospital carF and ph ;s; -, services were e::amined b•.: age and gender cateq,-~r-le,s ,:nd tested f'mr stati=_ti'caI =_ignir'icance. (~? Attributable risk., a me'asure of the ma;:irnal pr,,G~r'.i ~r uf hospiital utllization and physiJciani servrt_es attrlb..t~:a:_ tG S,nol: tnL] waa t_al cu1 ated . The Treva1 ence r,_te usatd w.: =_ `.t,et ccinfi';.nCct proportion of c;urr'ent and former smc~.et"S •.-• jJ_i~?ntl'a,l si71~_4rc~c-~ of Ova)rrst,lifla't,lon). Pela'tl,:?, r:Sl s 0-4tCJ the attr:bU.table rls:E> farmula were srrrO~:er' C=ne_-' =mcE,er ratios f,3r hospital' da•j+= and ph'y_ici,an ;) =rc,E iny-<;ttrihUtable hospital diiz•.= __ acd r'~•~~. UR1_At~-?~i]. +'~-Dr t•ha~* d L S:Ca~S??' rQ ur~l.:-5~ c'F 7- ~C,7~p L 85648429

.CcU'1at.=rrV ~.~ in~v 1,~:.~ p att.ribt:rta'ble sr.•I- :~<a: tstfs f,zr tha condi t l o rs ~.b`r aye ; g vrr.cG?r- -.± (4? (tii3es, 17-64 ~e'ar=- '•UFre' =oiT14TY-?s ~cdtr't'ta s:lng 1e Crc f:- r s; =ttnc ; w;t'hi a.ail:;ble t--, ealth rr.ar~ _ast dat; vt l.3kJie ' fL,r z gr?,s 6-4 r and under at3,=c_' OL- a ~Q (c E-tima+lit:~n rf s;noG:i'n~-attriU+_ttabl'e dir-pct herlth •-ara crs`= wr.•s acc-lt-lpltshed' using the following cor,.~ent-Lon: -'p:t '.<Kl L',t} L e--r1,i r, i_frS:l ny hojne,, and other Fri-, teSls 1 arl-3 L =er•~ice cc_it_ u4rre estimated Usi'lllig the attributable' rls. L.~r It:,_;pital ph:;sician ser.icas an'd' drt_ty _osts w_-r : Asti.,natr-d tht_' attribL.itablre risl:: for physician .1s.ti-i. Thi = procr.li,rw repre-ents an irnportant upqrade o-f =,,noG in-3- at'tri~utat,l'e LQ'I method~.5'1oy,1, the shi.' ft from trcrtal ityr to inurbid'i t,t rnea>.ures ~f ;d''irot_t ;.osts'. Hhwe,rer, use of t:torbid'it•/ comparisoni5 is not aComplete solutlon. Exce=_s l;~rb:c~lty in :--_in;:;G ers is not as well, doCLlmentedb'y age, gender, arrdl dl aqncai s code as e ccess mortal i ty. Data on use' 134"::t_Ltt7=1t1'~pnf mr?d1 =-31 ser_..iliCes 1s partl'CLIl':c;r1'V sP:4?1-ch'J. ruurthermori:?, thP logic of cost estimation a=_=_umes that, for a,;i ,e;-i degr~2e af i l ln?_•s, smol!:er , and nons;-~ :.it ct7iTlp?ra't:e ra'tes. Thl's ass!!lTiptLC.- 1=, m . + vU;-h.,+=^'t ed'' ',.- . ~loyt., artd Sch,W-?'i yzt•~r'' 3 ( 1'3Q.) stLtd , u+ 51C:F:ltiy, =^_'n.rci,- -t li=t C5 and Utlllzat'lon' pat'iFr'1E _tr,11 F:uis:- r-F'erm'ar~ntheallth p1<,n picpcllatiun. ~;r• . ra ~-,ad, --r-- e-rs; r.:f ~To-= hospital d~; = 1, ?r:/~J person-.•ear u =,-iri'..iyT :; t(:. n7 n•=in0 V ?r=- ',1r- =s f,h'a 'n ?,'•.pect'ed:l and' ;o4.1'tac;tl,-?nt -_t:.ilL-ation' drd n';-,t difiar between current and neoer S . Sm-;F.er swere .ess l il: el to see~ preventl.,e' ;-ai error in the appl'ica'ticin of prevalence-bas _c-, 1-1., I ,rc-:t`,'cds to lifestyl!e beha~iors such as cigarztte :ric:ude i'1l imprecisiLn in a'ttribi-~'table r1sE! e=_tim~te=. t'~`,`' i~ncompl'ete data on dlfferential mcrbidity for smoVers and n,onsmokers, (3) inc~mnl~_te d'atc on p~;tt.ern= ot util'iaation by smotring statL.ts, (4!" the gross agyr'egatlc~n n- econQlmilc dc3ta NJhich pcj,71 s ci'..,:Sts f:-3r l:ar.~ra i_at?y:or'ies _• d'i sease rather than f or i rrd i' .1 d~taI d'l seaJe=_ . (1S ~ erri-or : n the under'1ying tot.aL L0[1 astimates, and' (,3) error lnt, U; es-trapol'a'tilny from national data: to the yroup undler- St.i-ol :;. (z 4.20 METHODOLOGY AND SOFTWARE OPER'AT I'ONI N' ~. dlt . vuPP: _ed for' r9ewi _,_ -,. ~ L'-....11 .3~L'.:- Jr-i ~ ~i~T •]L "r...='L..*_ Fn.R~~A.y r~n, cc;/"~-- L:7~B t--:1 ~r~ L'1"1~-2 ~ t_~r`2 ~-. :...=r-. r ~ .;C

, _HUsp i ta? care 1!~q' -/)). ?[)(. F`hiys lLlan s sE-r'J1't_eS Nursi'ng home care DrUgs and drug satndrles -,2, ,,.;,:-) ,f v: ; Other professronaT services . . 4 .,t,;,:_„ .:., _ - 5.041 MEWYO'RK CITY: SMOKING-ATTRIBUTABLE INDIRECT MORTALITY COSTS a .. of sRIcG: 1 ng-re: :att:d ' u; .=c'. _== .it1C, Tie:~. 1:-:3:. cr'I-f~ I-!osGl ta 1 zuntd ofl rJr'rI ,.i Total personal he:-:l th $ 14, 1 L , 1. ~. . _ - - No_,,ita2 care . ..C/~,=~~i~l..i~:,n,s '~ s~er'w~~'1C~C.s ..' Cv u= , n q h o ', n a r, a r e 1 . ~ ~-} , 41' - DrU,QS and drug sundrl e= 01th2r prtcfes,ianaL servi _e5 ,t.. ~'.' . , The s+7+'twar'e dlstrit*!ute- these he;ltrr t_arre ctjsts 1'ni ac;_ordancr wlth the distrihution o+' 1990 U.S. n=.tllon_.,' ('7NCtllt,h' t_<=tre' Lost:s l 'ln, esC.P:m'cttlng th'e' f9^?;~tTOri Qt' t_ost nE 'P :L.i=T1L, t=1rCLl'La t::,Y"jt, ~snd ra s p7.lyd:to 1^`J fjls e c.s't3~:a r,`.iE i:'.]iilizlll l1 _F7 .:7~:~ts tt7r thi'"Sr~ d 'l,sre'ase '= arr mU l t: p '1 i ed t'y' tl'ie f'or hr~spltall care and fc~r yr, ;~~ciart •.l Sl ts CF:ice, Wodyazon, Sinshaiimer„ and Br•owner, 1^3~i ta.., appro~rimate the smo4:ing-attributat'Ie fra,Ztlon cf hE?--+l tlh 4.30 DATA SUMMFIRY' z~._r~: Sh1JF'INL~'-~:TTF:ISUTA'ELE D'IF:ECT HEi;L•T.H' C'rF'E N.3w 'iorEr (:it'•,'„ 193'' dol''larc '3I"iGF:: I NG -A TTIF: I BUTr";ELE D I F:ELT COS T;: F'1=r ~'Jn:ni (iie3i'th c'ctre', e:;penvitt_trtes: 5.~ 1~0 INDIRECT MOR'~TAL ITY' COSTS ,rtortaTlt": ci~~ts are the estlmated cost. ,ot , 6~i:..: ?r(:( P)~"~Ji~~L.,~='r,1 •1~1.t~ f ra ~~!UL. t,l.r(y f'rO1T1 G~ri?tn~a~t.l:!.r~? ~'".`l .. l.

to =!moE:imq-r'claledl ,:rd inju.r. Frar lndl .:cu -aia _'ie prematurel /, ,li' t~.-ut~ar-r' -=arr arP t Ur teir_ed .fle hLamelni cd'pl't cil this 1'C3'ii S' i7} incoifle T c J-ttzmated as the pre_;tant uf' future' aarn'i'ng';s. Tha inW'i rAct mor_taili tu c,.st est ilnO.'tes are' cCup,l ed'' to the ~`L;n'ate7 of sm0'.'.Lnn~-attrlbt t.:b1e' mort'all't'y for' the 3r,-:;:_Ip U s•r- stltd,, ec:r ea!=h ,dtagnn_is, smrol.:lng-attrlbU±ab'1e' ra:=ts' are' Ct7inputed as the sum Ct' th-3 Q'f the Pressnt vSl ue af fUture earn i,' ny=_ c'str ~r t ~ i,r,: •.kye and gendar i time= the nUmber of smo,4: ;n:g '-'at+':_r:ti_Etz't _m dle,:, ths fu-~r- each h;, ayra and gender categcrv- -r C~ Lr[• ~~n r•i~. 'rr .~. Cr~~C I~r.T' t.l;~,L_LiE t:, ~F FlJ~TUF:E E';;F.N~I7 G,f~ j:-E• 1 nD_, . ~P'1G~ = t~' tJ'r, ted' :t ate s, 1.98?=i: Di scc~~~m't F:ate = 4'<, .Hge Ma1es F:emales. ------------------------------------------------------------ _i-1 ~ 415',?93 ~' -7 1-4 4-'8 . 24I_ : 4 _'. ~l ~ : ~ ~ 479, 294 -79', '7 1 c~~7 5'~'9, _f 413', 1E 19 5T5', 3'55 443, 342 ~Ci~-~'4 6r_?4, 1'4 ', ~'E`= C~ 4 ~9~'~' 4 13 , 7i:~- ~I~-~F1~~ _ ~ . . . , J0~ ~~, JJ.i',. . 49_,0 8'I 4j-441 4 1 ". 77.E 717c[i . `-", 45-44 =25, 967 ~lv„3±lJ J4 2~5,464 1'67,i_'14 ==-=9 14u. 1 l~a 1! I 1.~41_ 60-54 44'S ~? , -8'_ 5"S - 6 9 7o-74 12, 666, `,:i. 75-79 6 , 1(:i3 9O-94 - ,,~~(:) 2 4,'4.: VJ `* 914 i'. 1~' 3L:,Urc?: Ri ce, Hodqson , and k:.opstPi n, 1936 H+uture strea'mi uf =arn'inys i''s callcUlated as the SLIm Gf i~. hi_iitUrC _.'nnl'1'c.,l E''3'r'i~Lt1~5 prlior to re.tlr"•?ment„ assuinln'y, a 3~t~raL~lr? ~rirti'~1 ~i Ln and an rnfl!atl`.n ratE. Th~= present ~a1'uz' of f'uture earnl•-:'qs is Lr _n,~La i:7:13u v fashi.:)n, but each term t s dll =_, ~;nt~.~,

if ter funr Haal th 'I"t',-o" r at.= -i l~~e. Hi,d~-. _ ~; •--,rt , ttn.i F t.::1 -. 1q°E! forr I,Sc"i, T•ab'1e =. ti,'; disNla,,= t'he'prt_=_errr 'aloe .- .-4a t~he a>/er~ a :lj,,e~ atin'Y!iilC~, li ..~':'' t..J: ?. .~. -: .. _ . --ifiei_+_'3'. The p:rr,:s=;- ts=;-t .;;.I.I:y ,fl tl.l'ti.lrr_: :z,rmtn-gS ersed' tm f'- .. u'. t.hC- Ncit..";1- 3: ft_t'•.ira ?,iirntn~.g= S .-.0 U lnt,ed at 4'., ._ -~rl~~a C f i tyaui-e-s ~~ ~Je.ni-2 ~r~A t~~-= d F''~~; iT, ~~ ~ ~~1 ca~~ a m d 'ro'1 I e a ;,d _!.~es ar P pro -+ ~u J c~=_ ^7r s,- ji•'ari' .nt~r Vall s ~sfiij ~t=Ci]tlnt f 7r ( l.%' 3q ;r?- -zk n'd •r~ p E3!-tf c life a p rcl-an'czAs, (2) patter-n=_ of' earniny,s ,.'-. ~dt.Tfc=rent ~y«=•~, r'i ]:abor force p;,rti_ii3.ati.on (I4,; i,mp,...ted valt_te f.Dr housa'keepiny and :5, +.J:., _' fLlt,:!ir? strezz~m' u•fi G+;?.rnllngs into its Fire=:?nt, worth L.' L'?C :C, ufIt Ic'1':!. ';•i =e andl :t7'.1,1e'C,g'LS'C' S l-ISeC both a. a•::, and .'. 'jl ='=c, ntf.x?' :! n nytlo n:a.L c: jt.lt'=.a-ll.a tl~7ns. The sGftWcira.. -+.1C1!' S,L'C.:tr(q : 1bUt'"tt,l,'? 1'ndl'r'ect tTio:rt a17Jty LGsT-, f c' Ji s-,~clrlt rates. Final est,imate= can be tnflatedl to 1 dkrr' y.e=•r dlr,i 1 ars' t'f =~.nnl,l'~1 irr_' ea='es if1' hm?J.r1''Y r,:,rnpen5ariun iin the bl_i=iness se'_tor. 2Rcau(_e aggregcted mcrtal rty data r=_: Used„ i t i s g'eneral. 1' ;~ ni-.,t pc-srible' to ~jliff'eranti ate lndi•ridu'al smcEkimyr-related death's from othwr. de'ath s with the same cau_=.e-of-dGrth codle. Tilatrar'nr~. wLthln e'ach t_aLtsa-of-death related tn, smcck:ang„ it i1s a'S_uime•d that the distribl:.ltion of' age cf death 1'=_ t'•1ert.i:- _.:1 f;nr- <.ll rieat.h- = and fcr the srnol!:inyr-~'ttriblltc~,; ='r ac++; ,_~i of t:ho5e dcaths. Thi s i s a comservati •re 3 >!_cT~,; ~ l I1n a -si11c)[f 1'iyi, 1'3I StrQn gl'yf' I mQ LL'_.Kt ad ' l n P_~r l d?'=' `. 5. 2,'Cy' SUMMARY OF METHODS t-J' t'!.. C 1't.; ytm 'I'tdt•r-s p 'H-- r_ii= :3tTioV lnq pre•.,;.-s le ncm rHtr -s G•-i5 cS c triOr t al 2i t',+ d!atal f c: r tht: d l a'~no51 ~Jo r = I''._rei into the spreaij'snaet. l+llth this the so:•*k•Jr,, •- .,,'«?r Ca1CU 12:t.?s s'fncS l,ni-i -a }~rllb ..lt~tile' 1T1ortz- 1.1~ .,-ir_ ,nales and' females b•y i'n't u:ict_,a1 iil-Ag nc,=i=n pFsident ,n spreadsheet are tabl:e=_ of the pre=ent vai~!e' of ft_Itu r:a •E'arm T ngs d'1 scOUnt?''t •1 t 4. f-;itnci l? ~ ,aar age grou!P. De'td iS rE-g,3 t,?d' IrfO f0 lr c.~= _,a-44, 45-b4. 65-,4, 7'jI and The'ze aL3e hr sL.!mmed t0 provlde the esti tnG h e of t•Jt al gmo~ t.rndirect' m!Jrtal'it/ fkDr e,:k,_h T~te acftware pro•ri',d'es gender-=_peclflc indirect mortal'it., -.r.. z=+';ma+`e=_- f;-Ir t'ha<-:,~ atga- br.ac4:et., byr indi.id!_Iall :~_~rtcs;.s arrd, b• Wllay',-to=_ti,_ cateL3or•:, amd disa:la~,s 1iot-k1l ;nf t'r-:t,l.lt<,b1«: cros* s. These dA t a ;it ra a 1's:.a Fres;? n se:.ts comb~.nedb r;Ii data are uomN~,ted ior -, di=+-riu;nt r,.,t.es, 4: and .5'.. 5~. -D'' D!A'TA~~ SUMMAR~Y~ 8!i648'433

Table W. =A: ANNUAL SMGF:If!dG-hTTF:IB`UTHBLE - It`JDI=:ECT MOF?TrLIT'e CGSTS' DE:It~~i]!JPUTED ;~T 4". fJeua Yc~r 4!C.'i ty.(19St_i~ d'o11 arr s) :ahE t3Fa7UF' MALES : FEMALE'S Bi0 'Tf1 3: E - !_"= (mi1lions) . (mi11'ic+ns) :mi1'i::- 7,',,+ I ,)C1.() 1'~'L. :3-1'-. _ -4-1 C `2.. 4 5L3. (") 4 • 4 5-~a-4 _-•4'. 5 1~:iC. :) 4' bu.-74 '~. 1 C4. C J~. i + •T1. J. L 7 . ~ New Ycirl: Cit•~ (estl1mated 19°T dv11%,r=: AhE GF:OUF' MhLES FEMALES EtOTw SEXES (~mi'11i~ons~) ~ ('~m~iLlio~n=_)~~ ~ ~ (m:i1~::1!on=), '91 . C C'"(7 . Ci 1'.•! 1 i. i :'T2.9 ~7. C 1 445 1^_. 4 6,5 74 4'C. L 11.4 6.00 NEW' YORk; CI'TY: SMOIk:INS-ATTRIBUTABLE INDIRECT'MORBIDITY' COSTS 6.10 INDIRECT MORBIDITY'COSTS'. Smoking-attri'but•,t;: _LnU;r,_t_t mizrbidit-.• costs ara the .:)f liost income and pr-oductUl.t•;- fcr indl•lidi-taTs whc are d'i sabl'ed by nonf atal or sl owl y f'at.al' smoi> i ny-re L',,,ted iliness, Srnod::ing-attribut'able' prodLacti•.:it;.: TcJJ=_'`= ara k~ t~t! r^gtj aS WdyZS, Sa.i ll' i e,5, dnd Sla47p 1'e,flZJntS f rO,T Fr; om vrcr.:. among cUrrrentl y cmpi o;.-ed aerrsons, Lcny-te-r a; }a'b11,I f_:, cj"t"y5 A;n'dI ~q=PItd1 iz'atl,ort dar s f'Jr s,TG7Grin,y- rn~ attr':.b;.,tabie c'al,.,ses: and the impUted v'alue of F,cr_i_r+eep r . 1 = r +ema l a'~ii l.Un.~L7l a tv l, eep h(-j l_l «e br+ e :) t Tm,:; ~ in~y-indU ced :11'ne=s, I ".r~r _:Oiilp inr~T'-1:i'.l d .:~t,`,. t~=. L.,=-? ' and : ~t i.e t, - : _. =p ll'-'~ r_l' mC;t .hCJlj',i_1Jy+ S1m11'ar to the d ir'e Lt Cr.1 sf' Vy1= t:-

r . ~ pro,_e+d Lir~ ~iT.Cny ` l i^`f F 1 ~~ ti_ h ~. ~_ ci~ 6,;rrP_~ u~; .:... ~J!'" v'~2@ hOC:=E'. r r'nlc'r' J<+ u .,..s2.s '. +Df ri~a1Jr.a ~i H 'E''.?,.~.~~.'?':h ~ i~~nf.e_'_':, r .. n' .=--:?rj f or .3.' :7 .~+". i, ]'n - _., ..- .~ a.. y" al't~ii g'Peh~u~~,cr, ,~. a~^i,~, ._!~'Ct r ...li',.jl , ~ .. , 3. i ~f' _al.,tj.+jr_~-~.L_~a+~' -r_..~.i!•_e , p ;ric4j~~ /irYTTlllriL ll~~rZ 'tr~•-.. . .. ~. r. __. f~b, i=. L i , o the g,rmt_ip, uu- d4=r !-.',:'d' . i . e, PJt.~ ~ ! '.-I+.::>h i?~~. :=:~Ci'4•r"Nar%?I tLnn~".~.'..IT~~~~. ~_. _. S ,i ..r~Ly, .~vUdt,~.h'.Ia ~ Cb'Jb t,..'7:'.?. r ~..~.!. .., -. .. r f~Jh- d7..~ fn,-D C'~,( r'O'.r-:-. >, nc) r!:, : ~j i ~~#i ~ b; ~~ F=i:r,;i ,y,rn I,r Lr p r 3 p t:ucr tc ,!;re=. Ti'i.a pr0Pur ti:7r:3i ...5't,irTl3t•.i 7n Orf' indir^Ct _-;mp•.tt -d e's fo',.i 1,7j ua ;; :,L;;a,~ Lh..t. ',Ch._s1 cmsts .U.`.7.t Dtt ~+ast~ iJ.S'., + Ilndir"~ct ~c =_t~ J.~. i _ ., ~1.av! --+ t: C t,+ .: , 1'tld l ^ =C t tT(D rt 1 ~J 1 t :F.i.i'ttitp2ijir f!=ir ?=e=il 3 jtq ' 3r+~ ^•~F?i 17 _ fs. 2`O SUMMARY OF METHODS Th'e sof t w a re user p r a ': :, d!?- a y ~- -z .r+,J j;rn-` r--CP W _. for direct and ind'1~ -ect •-tur tal.''l t+ ..-I ILies) for tFhe' ,yrnup Wnder =tu+!•, r~,. ~ :'n r;l' b. I d L, }'J G o s f.=- 3 r F t'_:;'" ! Ti 4F;t,'r. d T, i? t h t r! Er. j'i =F +1u_4tf.;;urt '7f 11 ... :. I a ta =- in..:1Gr: n j-:_rt t" , bt. ,~j :'r' -..•7 t' _ _ !~ .rI J=,-r.~ S1n'zf`io'2'i d1?7dBrUwnerf L.CF`C:, ~1 . 6'..'0 DATA SUMMARY `rc_! .."Jl3 =,'7 !; 1 _'tJT~6'L2 85648435

INL'IF:ECT '.,..r 77ST'z AGE GkOUP. .1 2` ?-5 -2 ,tC+ M:,LEw FEMALES .(millians) (miilionsi riCTM •3E x E:=. (;ni 111~n~) NEW YrRF CITY: COMF~3SITE :'M17V I1'aG-ATTF;IBUTAELE CS='= :. The final sprcad="' ec-+_ sLLms dir_ct, indirect mcrtality, and .. ---timat_d indirect inorbidit, costs tc provide an zstimated - :-ilue for tota:l smol:ing-attribttt'able costs for the groUp ~rnder study f,Jr ina,le=_« femal'es., both, se;ces, and fcr itg_~'g,ender-sp=cif'ic subyrcLups. The percentage distribut:on ,~f' tc~t •,1 costs by te pA of cost i s computed. T.3b: _'.+:)Fp' jl_MMAFi'( OF SML^~ I'NG-ATTF;I$UTr16LE COSTS Clew Yor4; Cit•; (198'C dollars) _ L I F:ECT COSTS IhlDIRECT MQF:TAL I T'i'' COiSTS' I'^lDIRECT' MORBI D'I TY COSTS TOTAL COSTS + 542',128,0'52' 781,159,651 327,212,,6I6 1,650,500,319 _ r:i-6 4 350-,,785,285' 728, 3791, 52'1 3115,048,183 1,404,212,989 65+ 181,342,767 52,780,130 12,164,433' 246,287,330 FE!'!'tALES' _ C0+ 435.I068,52'5. 23'0,003,214 155,027,349 820,099,088 =Ct-64 257,932.68'9'. 189,507',575 151,915,661 599„3'55,925 7~* 177',135',83b'.: 40,4951*639' 3',151„68'8 220,,743',16'3 0 ELTH SEXE S C1T' ~ =`'-''+ 977,196',577 1,011,162'.865' 479,693,314 2,468',052,758' ~ ~-J-64 618,,717,974 '4 917,887,09'6: 464,072„73'0 2,000,,677,800 rCy. ~ .L-11'+ 358',,478,603 93,2751,770 15,620,583 467„374,9'S6'

tJ[111[](ll][][][1LJL1LJL1l1lJ11[JIJlJC1lJ[1C1[]C]C~C)I,JLJLJLJLILJLJLILJL1L1lJLJLJL1i1l11111~JI 1lJLJl~t ll /l ~t it ~t [ ] 1 ' . = 1 I [ ] f 1 , f 1 , a, I t l [![][]C]E]E]H[]El(][lE]C]ElE][]Cl[][iC)flElE]HE)I][]f]C][]C]C]flC]C][][lE3{]Cl[]C][][1[][][][][][~E7 Clflflfltit]1.If 11 1 , [iSt9uk1NG-ATTRIBUTABLE COSTS FOP GROUP UNDER 57UDY SUM OF II [] DIRECT AND"'. " ESTIMATED " I1 C9 INDIRECT INDIRECT INDIf~ECI'..,. ESTIMATECI I I [] GENDER/ DIRECT MORTALITY MORTALITY MORBIDITY_ 'e TOTAL 1I C] AGE CATE60_RY COSTS COSTS COSTS COSTS COSTS I1 I (lf][l[][]Clf][][]C][]f]ClC]C]f]CiC]ClC][iClClCI[lf]f][]C][]EICIC][]ff][]C]flClC][]C][]flf](l[][7[lC it.lf][][lfi[]f 11 11 I []PY3LES: ALL AGES - - - $542,128,052 i791 , 159, 651 f 1, 525, 29?, 70:~ Cl ~C][]C]E]C][lf](]C]C][]C)C][]C]C][]C][]C)El[] -- ---- - []MALES: 2¢-64 YEARS ~[] DATA s36©,765,2e5 f?28,379,521 Cl $1,089,164,006 C] C] ENTRY , E] []MALES: 65+ YEARS [] CELLS $181,342,767 $52,780,130 Cl S234,122,697 C] f][]C][]E][]tl[]C)C][][]C7[][)ClC]ElC][7C][7 Cl []FEMHLESq ALL AGES $435,068,525 $230,003,214 $665,071,739 Cl C][)C]C][]C][][)f]E]EHC]ElE]f]f)E]E]C)C3E][] []FEMALES: 2©-61 YEARS Cl OATA $257,932,689 $189,507,575 f] $447,440,264 E] , 11 ENTRY 11 E IFEMALES: 65+ YEARS [] CELLS , $177,135.836 ' f40, 495, 639 E l $217,631,475 Cl E][3E][][JCI~I[)ElC]CICIC][]C]C][lC]ClC)[]C] [l' [ l GOTH SEXES: ALL AGES ,., $977,196,577 t 1, O1 1, 16-c~, 665 'l 1, 966, 359, 442 (I []BOTH SE?SES: 20-64 YEAR S ~f616,717,974 J<917,987,096 >E1,536,6U5,Q74 El : [ )E~tITH SExES: 65+ YEARS 15358,176,603 t93, 275, 77U $151,754,575 f ].. ' - I l 11 Jl JL J[ Jl JL JL Jl JL JL JL JL JE 1[ JL JL JL JL JL ]L JL 1L 1L JL JL JL JL )L JL JL Jl JL JL JL JL JL_ JE ]E ]L Jl J( JL JL JL JL JL ]E )C J[ 1[ ][ It )l 11 1l 1[ ]1 11 11 1 - - []PERI:ENT DISTRIBUTION BY TYPE OF COST_ SUM OF ~~ []FOR GROUP UNDER STUDY DIRECT AND ESTIMATED I t lI INDIRECT INDIRECT INDIRECT A ESTIMATED II Cl GENDER/ DIRECT MORTALITY MORTALITY MORBIDITY_ f~::TElL I 1 - 1' ] AGE CATE6ORY COSTS COSTS COSTS COSTS 1 Il~~l 1 1 I 1 [][]C3Elt]E]E]C)[]ClC][]Clf]C)C)f)C)CICI[lC]C][]ClC]C][][]C]E][]C7[][~CIC][]Cl[)C]fi[lflf][][][)Cl[] [)f][][l[][1[lf 1t 11 I []MALES: ALL AGES .'32. A5G 47. 33? 00. 1 7 i' 19. E13t4 100. E] ' []MALES: 20-64 YEARS 25.69'. 51 . B7'f_ i~7. 56i 22. 44i: 100. O-~t E] _ I 1 []MALES: 65+ YEARS 73. 63~ 21. 43i; 95. 06r [) 4. 94i; 100. (?E~::1 1 [] 1 1 ~ S ' I t [ ]FEMALES: ALL AGES 53.05? 29.05:; 91 . lOr 1t3.90C~ 1~~~~,r(~:.I t E ] 1 1 C]FEMHLES: 20-64 YEARS 43.05X • 31. 62.. 74.65% 1.~0. OrJ:'I 1 f 7 9p _5q;: 1 . 41,: t0o • n~',::t ( 132,~ , 212, 616 .;1 , 65G~, 500, _. 1 `? 1 I II'f 2,=+~i'+ II E315,049,1e5 $1, 404, 21 - 11 ;12,164,433 ;216,2B1,'~30 1 1 II $155,027,349 $820,095l,OE~[i~' l1 f151,915,661 $599,`35a,92a 11 1 1 S3,111,688 J:22Q, 743, 16'S 1 1 ll I t $479, 69'~3' , 314 t2, 466, 052, ; 5E. [ 1 ( i $464,072,730 f2,000,67T,f1UG (1 EI S15,620,583 346?, 3?4 ,~+-i~. I; 1 ----- - - 4MV999