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6 I I I I I I I I I I I I I I COSTS OF SMOKING, BENEFITS OF QUITTTNG 387 women between the ages of 35 and 79. Our benefit estimates for light, moderate, and heavy smokers are reported in 5-year age groups, and were tallied in 1980 dollars using the same real rates of discount and productivity growth that were used to calculate the costs of smoking. Benefits were measured against the costs that were likely to be generated by individuals who continued to smoke an iden- tical amount throughout their lifetimes. In addition, we assumed that once a smoker quit, it would be for life. Our estimates of the benefits of quitting are not surprising in light of our findings regarding the costs of smoking. The greatest benefits were found to be associated with reduced risks of developing emphysema, although they are sizable irrespec- tive of disease condition. For example, for men ages 40-44 who are moderate smokers, the benefits of quitting associated with reduced risks of lung cancer, CHD, and emphysema are, respectively, about 54,300, $3,900, and $11, 100; the corresponding figures for women are approximately $1,500, $300, and $3,800. As expected, these benefits are consistently higher for those who were formerly heavy smokers, and are greatest for persons in the youngest age groups. Summation of benefits across the three diseases suggests that the total benefits of quitting are sizable.8 For male heavy smokers under the age of 45, the present value of total lifetime dollar benefits is about $34,000, and for women, the cor- responding total is over 512,000. Even for the very oldest age groups (i.e., age 70 and over), the total benefits of quitting are by no means inconsequential. For men, they range from about $600 to slightly over 52,500; for women, the range is from S400 to about 53,000. DISCUSSION This study has found that the expected costs of cigarette smoking for individual smokers are substantial. While these costs vary with sex, age, and the amount smoked, there was no group of smokers that was not expected to generate sizable losses. Furthermore, the results of this study have shown that, at any age, it literally pays to stop smoking, since the benefits of quitting are also sizable. The relative effectiveness of smoking cessation may be conveniently assessed by computing ratios of the overall benefits of quitting to the total costs of smoking.9 What each reveals is the expected proportion of smoking-related losses that a given smoker can avoid by quitting. In a sense, these ratios indicate the extent of "cost recovery" possible; the higher this ratio, the greater the relative benefits of quitting. s Considerations similar to those noted in footnote 7 apply to the addition of benefits-of-quitting estimates across diseases. s While these cost recovery ratios are equal to the ratio of the benefits of quitting to the costs of smoking, it is not a beneflit-cost ratio in the traditional sense. A benefit-cost ratio compares the benefits and costs of one specific course of action, while the ratio of the benefits of quitting to the costs of smoking compares the results of two alternative courses of action (i.e., quitting vs continuing to smoke). Related to this difference is the fact that our cost recovery ratios will always be less than I since an exsmoker's risk of developing a smoking-related disease does not return to that of a nonsmoker for a number of years after smoking cessation. Consequently, the bene®ts of quitting for an exsmoker can never be as great, in absolute terms, as the costs of continuing to smoke.

388 OSTER, COLDTIZ, AND KELLY I I I TABLE 4 TorAr. CosT RECOVErsY RATtos FoR LiGHr, MoDEJL+TE, AND HEAvY SatoKERs Light smokers Moderate smokers Heavy smokers I Mea 35-39 0.586 0.644 0.666 40-44 0.548 0.581 0.600 45 -49 50-54 0.500 0.511 0.462 0.461 0.511 0.491 I 55-59 0.438 0.417 0.457 60-64 0.421 0.405 0.459 65-69 0.402 0.386 0.450 I 70-74 0.368 0.351 0.418 75-79 0.331 0.329 0.322 Women 35-39 0.555 0.631 0.650 a 40-44 0.536 0.603 0.642 45-49 0.517 0.569 0.613 50-54 0.501 0.545 0.593 55-59 0.479 0.514 0.576 I 60-64 0.454 0.493 0.569 65-69 0.407 0.450 0.528 70-74 0.396 0.441 0.518 75-79 0.386 0.429 0.504 -1 Estimated cost recovery ratios for men and women are presented in Table 4. Although these ratios are highest for younger smokers, it is apparent that it is literally never too late to stop smoking. While quitters below the age of 45 are likely to avoid between 54 and 67% of expected lifetime losses due to smoking, even those over the age of 70 are likely to avoid between 32 and 52% of these~ expected losses. Our findings have many potential uses. For individual smokers, they may pro- vide yet another powerful argument against smoking. Similarly, physicians may~ find them useful in encouraging their patients to quit smoking. Corporate decision makers also may find our estimates useful in their attempts to evaluate the cost effectiveness of employer-sponsored smoking cessation programs. Finally, our study undoubtedly will prove useful to policymakers in government as they in-I creasingly turn their attention to the economic burden of the health consequences of cigarette smoking and the question of who should ultimately pay these stag-~ gering costs R. REFERENCES 1. Cady. B. Cost of smoking. New Engi. J. Afed. 308. 1105 (19E3). 2. Diener. C. F.. and Burrows. B. Further observations on the course and prognosis of chroni obstructive lung disease. Amer. Rev. Resp. Dis. 11, 719-724 (1975). 3. Ferris. B. G.. Chen. S. P.. and Mutphy, L. H. Chronic nonspecific respiratory disease in Berlin. New Hampshire: A further follow-up study. Amer. Rev. Resp. Dis. 113. 475-485 (1976). 4. Fletcher. D.. and Peto. R. The natural history of chronic airflow obstruction. Brir. Med. J. 1. 1645-1648 (1977).

1. ~ I I I I I I I I I I I I COSTS OF SMOKING, BENEFITS OF QUITTING 389 5. Fletcher. D.. Peto. R.. Tinker. C., and Speizer. F. E. "The Natural History of Chronic Bronchitis and Emphysema. An Eight-Year Study of Early Chronic Obstructive Lung Disease in Working Men in London." Oxford Univ. Press, Oxford. 1976. 6. "The Framingham Study. An Epidemiological Investigation of Cardiovascular Disease. Section 26: Some Characteristics Related to the incidence of Cardiovascular Disease and Death; Fra- mingham Study. 16-Year Follow-up." Department of Health. Education, and Welfare. Wash- ington. D.C.. 1970. 7. "The Framinghatn Study. An Epidemiological lnvestigation of Cardiovascular Disease, Section 30: Some Characteristics Related to the Incidence of Cardiovascular Disease and Death: Fra- mingham Study. 18-Year Follow-up." Department of Health. Education, and Welfare. Wash- ington. D.C.. 1974. 8. Garfinkel. L. Cancer mortality in non-smokers: Prospective study of the American Cancer So- ciety. J. Narf. Cancer Inst. 65, 1169-1173 (1980). 9. Hammond. E. C.. and Seidman, H. Smoking and cancer in the United States. Prev. Med. 9, 169- 173 (1980). 10. Hammond. E. C. Smoking in relation to the death rates of one million men and women, in "Epidemiologic Approaches to the Study of Cancer and Other Chronic Diseases" (W. Haen- szel. Ed.), National Cancer Institute Monograph No. 19. U.S. Govt. Printing Office, Wash- ington. D.C., 1966. 11. Hartunian. N. S.. Smart. C. N., and Thompson. M. S. "The Incidence and Economic Costs of Major Health Impairments." Heath, Boston. 1981. 12. Kleinbaum. D. G.. Kupper. L. L.. and Morgenstern, H. "Epidemiologic Research, Principles and Quantitative Methods." Lifetime Learning Pub., Beltnont. Calif.. 1982. 13. Luce, B. R., and Schweitzer. S. O. Smoking and alcohol abuse: A comp.rison of the economic consequences. New Engf. J. Med. 298, 569-571 (1978). 14. Luce. B. R.. and Schweitzer, S. O. The economics of smoking-induced illness, in "Research on Smoking Behavior" (M. E. Jarvik. J. W. Cullen. E. R. Gritz, et al., Eds.). National Institute on Drug Abuse Research Monograph 17. U.S. Govt. Printing Office. Washington, D.C.. 1977. 15. National Cancer Institute. "Surveillance. Epidemiology, and End Results: Incidence and Mor- tality Data. 1973-1977," National Cancer Institute Monograph No. 57, NIH Pub. No. 81-2330. National Institutes of Health, Washinjton, D.C.. 1981. 16. National Center for Health Statistics. "Prevalence of Selected Chronic Respiratory Conditions, United States, 1970." Vital and Health Statistics. Series 10. No. 84. DHEW Pub. No. (HRA) 74-1511, 1974. 17. Oster, G.. Colditz. G. A., and Kelly. N. L. "The Economic Costs of Smoking and Benefits of Quitting." Heath, Boston. 1984. 18. Rice, D. P. "Estimating the Cost of Illness." Health Economics Series, No. 6. PHS Pub. No. 947-6. U.S. Govt. Printing Office, Washington. D.C., 1966. 19. U.S. Dept. of Health. Education and Welfare. "Report of the Advisory Committee to the Surgeon General of the Public Health Service," DHEW Pub. No. (PHS) 1103. U.S. Govt. Printing Office, Washington. D.C., '1964. 20. U.S. Dept. of Health, Education and Welfare. "Smoking and Health-A Report of the Surgeon General," DHEW Pub. No. (PHS) 79-50066. U.S. Govt. Printing Office, Washington, D.C., 1979. 21. U.S. Dept. of Health and Human Services. "The Changing Cigarette-A Report of the Surgeon General." DHHS Pub. No. (PHS) 81-50156. U.S. Govt. Printing Office, Washington, D.C., 1981. 22. U.S. Department of Health and Human Services. "The Health Consequences of Smoking: Cancer-A Report of the Surgeon General." DHHS Pub. No. (PHS) 82-50179. U.S. Govt. Printing Office, Washington, D.C.. 1982. I