SMOKERS' BURDEN ON SOCIETY:
MYTH AND REALITY IN CANADA

Introduction

"The net result [of smoking in Canada] is the it costs each Canadian $100 annually in health care costs so that 35% of their countrymen can smoke."

It is the purpose on this article to determine if observations such as this one are valid or not. The analysis is based on two fundamental concepts or criteria: externalities and inter-group transfers. A smoker may be responsible for hospitalization costs which become an external cost in Canada given the public nature of the health care system. In this instance, the smokers imposes a cost to others. The question then arises: who pays for what and who benefits between smokers and non-smokers. This calls from an examination of transfers between the two groups. In the previous example, non-smokers finance a good portion of supplementary health costs, so that transfers go from non-smokers to smokers. On the other hand, smokers pay taxes on tobacco which benefits non-smokers to a large extent. In this case, the transfers go in the opposite direction. A complete balance sheet of revenues and expenditures accruing to smokers and non-smokers is necessary before one can conclude whether or not smokers are a burden on non-smokers.

Basic Assumptions

1) Smoking is harmful to the health of smokers
2) Smoking is not harmful to the health of non-smokers
3) Smokers know that smoking is detrimental to their health

Smoking is Harmful to Smokers

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The Health of Non-smokers

"Involuntary smoking is a cause of disease, including lung cancer, in healthy non-smokers." We found however that the evidence in support of this opinion is far from conclusive.

Concerning lung cancer among spouses, the 1986 review of the US Surgeon General is largely an examination of three prospectives and ten retrospective studies. Highlights of these findings, provided in his tables 7, 8, and 9, can be found on our Table 2.

TABLE 2 - Summary results on passive smoking relative risk coefficients for lung cancer

STUDY	SAMPLE	CANCERS	SIGNIFICANT RESULTS AT 5%
Hirayama 1981, 1983, 1984	91,450	200	= 1.9 for women whose husbands smoked more than 20 cigarettes daily
Garfinkel 1981	175,739	153	none
Gillis et al.	2,744	14	None

Retrospective studies

STUDY	..............	CANCERS	SIGNIFICANT RESULTS AT 5%
Trichopulos 1981, 1983, 1984		77	= 2.5 for women whose husbands smoked more than 20 cigarettes daily
Correa et al.		30	= 3.1 for those whose partners smoked more than 40 packs yearly
Chan and Fung 1982		54	None
Koo et al. 1983, 1984		88	None
Kabat and Wyander 1984		78	None
Wu et al.		29	None
Grafinkel et al. 1985		47	= 2.1 for women whose husbands smoked more than 20 cigarettes daily
Lee et al.		47	None
Akiba et al.		103	None
Perahagen (in print)		67	None

Source: US DEpartment of Health and Human Services 9USDHHS, 1986)

"Among the published studies on involuntary smoking, this is the only one involving independent verification of the diagnoses of all case. This verification showed that 13 percent of the cases classified as lung cancer were not primary cancers of the lung. This study showed that 40 percent of the women with lung cancer who had been classified as non-smokers (or smoking not stated) on hospital records had actually smoked, compared with 9 percent of the controls. The inclusion of lung cancer patients who had actually smoked, would have substantially increased the odds ratio with involuntary smoking, because 81 percent of the potentially mis-classified cases had husbands who smoked, compared with 68 percent of the 'true' non-smoking patients with lung cancer."

Other remark by the Surgeon General deserve attention. For example, on page 91 of the same report, we find this observation concerning tobacco use by parents:

"None of the studies with data on parental smoking had sufficient numbers to examine the effects of parental smoking on non-smokers."

Similarly, we find this observation about the use of tobacco in the workplace:

"The workplace, an important source of tobacco smoke exposure, was not considered in the early studies on involuntary smoking. Later case-control studies provided some information on tobacco exposure at work, but the data were limited and inconclusive"

Concerning the relationship of 'passive' smoking to other cancers, the Surgeon General writes:

"There are, at present, insufficient data to adequately evaluate the role of involuntary smoking in adult cancers other than primary carcinoma of the lung."

With regard to cardiovascular disease, the Surgeon General writes:

"More detailed characterizations of exposure to ETS (Environmental Tobacco Smoke) and specific types of cardiovascular disease associated with this exposure are needed before an effect of involuntary smoking on the etiology of cardiovascular disease can be established." For all these reasons, we assume in this study that smoking is not a cause of death among non-smokers.

Smokers Know that Smoking is Detrimental to Their Health

Indeed, such warnings must occupy an area equal to 20 percent of the principal panel of the cigarette pack. They must be 'legible and prominently displayed in contrasting colours', and the message is unambiguous.

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Conclusion

We have shown instead that the net additional external costs borne by non-smokers worked out for $244 million for Canada in 1986. However, smokers are responsible for a much larger transfer flow in the other direction. In the pension area alone, non-smokers benefit from a transfer of 1.4 billion mainly because smokers tend to die before non-smokers do if we use risk coefficient established by the medical profession. Finally, the massive tax burden borne by smokers alone means that they account for a further transfer of close to $3.2 billion to the benefit of non-smokers. Overall, as Table 5 indicates, smokers make a net overall contribution of $4.3 billion [per year] to the benefits of non-smokers.

Whatever the degree of risk or danger attributed to tobacco, the validity and direction of these conclusions remain unchanged.