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1. Introduction

This publication presents data on the cost of smoking to the NHS in England in 2015. It shows that

These analyses were undertaken by Public Health England (PHE) to support the development of the new Tobacco Control Plan for England.

The data were taken from a variety of sources, described in each section below.

2. Primary care settings

In 2015 there were an estimated 7.3 million current smokers and 14.8 million former smokers aged 18 and over in England. Prevalence estimates were derived using official mid-year populations statistics^{[footnote 1]} and smoking status data broken down by age and gender were taken from the Annual Population Survey (APS).

Current and former smokers are more likely to require primary care services than those who have never smoked. Excess primary care events (the difference between usage of services between current smokers and never smokers; and former smokers and never smokers) were taken from the 2006 General Lifestyle Survey (GLS), as used in the NICE Tobacco Return on Investment Tool^{[footnote 2]}.

Unit costs^{[footnote 3]} were applied to the smoking-related excess events, resulting in the estimates of costs below.

Primary care event	Estimated smoking-related burden
GP visit	拢794 million
Practice nurse visit	拢111.7 million
Prescriptions	拢144.8 million
Total	拢1.1 billion

3. Secondary care settings

3.1 Outpatients

The GLS also provided estimates of excess outpatient visits in hospitals which amount to an estimated 拢696.6 million nationally in 2015.

3.2 Smoking attributable hospital admissions

In 2015 to 2016, there were approximately 520,000 smoking attributable hospital admissions in people aged 35 and over in England.^{[footnote 4]}

The cost of these admissions was calculated by PHE using data from Hospital Episode Statistics (HES), smoking prevalence calculated by PHE using the APS, carried out by the Office for National Statistics (ONS), and ONS population statistics.

The cost per head of population in England in 2015 to 2016 was 拢27.74, amounting to a total cost of approximately 拢851.6 million.

Smoking attributable admissions are defined as spells where the primary diagnosis of the admission episode is attributable to the following ICD-10 codes:

• malignant neoplasms: lip, oral cavity, pharynx (C00 to C14), oesophagus (C15), stomach (C16), pancreas (C25), larynx (C32), trachea, lung, bronchus (C33-C34), cervix uteri (C53), kidney and renal pelvis (C64 to C66, C68), urinary bladder (C67), acute myeloid leukaemia (C92), unspecified site (C80)
• cardiovascular diseases: ischaemic heart disease (I20 to I25), other heart disease (I00 to I09, I26 to I51), cerebrovascular disease (I60 to I69), atherosclerosis (I70), aortic aneurysm (I71), other arterial disease (I72 to I78)
• respiratory diseases: pneumonia, influenza (J10 to J18), bronchitis, emphysema (J40 to J43), chronic airway obstruction (J44)
• diseases of the digestive system: stomach ulcer, duodenal ulcer (K25 to K27), Crohn鈥檚 disease (K50), periodontal disease (K05)
• other diseases: age related cataract (H25), hip fracture (S72.0 to S72.2), spontaneous abortion (O03)

The smoking attributable admissions were identified on the basis of the primary diagnosis of the admission episode, whereas the costs are for the full hospital spell rather than the admission episode. The cost of the full hospital spell was calculated using the standard Payment by Results (PbR) methodology. Spells with the smoking attributable primary diagnosis on admission were selected and the dominant Healthcare Resource Group (HRG) was identified using the HES field 鈥楽US generated core Spell HRG鈥�. Where the HES field 鈥楽US generated core Spell HRG鈥� was not available, the HRG attributed to the admission episode was used. This may result in the cost of these admissions being underestimated. The cost of the HRG was attached using the Department of Health (DH) admitted patient care tariff.

The total spell length of stay was identified from the spell鈥檚 discharge information using the HES field 鈥楽pell Duration鈥� in the final episode of the spell. Where the overall spell duration was not available, the episode duration of the admission episode was used. This may result in the cost of these admissions being underestimated. Adjustments were then made for short stay and long stay admissions according to the DH PbR guidance.

Top-ups were applied for specialised services such as spinal surgery, neurosciences and orthopaedic, using the clinical coding contained within the admission episode. Following this, the market forces factor was applied to adjust the cost of the spell. This was to take into account a range of local factors associated with providing that service, such as staffing costs and location.

Finally, the relevant smoking attributable fraction (SAF) was applied to the total cost of the spell, to get the smoking attributable cost of the spell.

It鈥檚 important to note that this cost includes only those spells where the associated HRG has a national cost. Those HRGs with a locally determined cost have not been included in this calculation.

For full details of the calculation of costs see the DH PbR guidance for 2015 to 2016.^{[footnote 5]}

4. Summary

The total costs outlined in the above sections can be summarised as below.

NHS event	Estimated smoking-related burden
GP visit	拢794 million
Practice nurse visit	拢111.7 million
Prescriptions	拢144.8 million
Outpatient visit	拢696.6 million
Hospital admission	拢851.6 million
Total	拢2.6 billion