Counting the Toll of Smoking-Attributable Hospitalisations

Abstract

Aim
In Ireland, 20% of adults smoke. Many current and ex-smokers live with ill-health and disability as a result of smoking, and this study aimed to quantify the extent of smoking-related hospitalisations in Irish publicly-funded hospitals.
Methods
A population attributable fractions approach was used in this analysis utilising smoking prevalence data from the Healthy Ireland Survey and combining this with internationally-recognised relative-risks for current and past smoking, and hospitalisation data and hospital base costs data sourced from HIPE, for the years 2011-2016.
Results
In 2016, there were 21,486 day case admissions, 33,615 inpatient hospital admissions consuming 309,117 bed days, attributable to smoking and exposure to second-hand smoke, with an estimated cost of €172 million in publicly funded hospitals. This represents 2% of day case admissions, 5% of inpatient admissions, and 8% of inpatient bed days for that year.
Conclusion
Smoking continues to cause a considerable impact on hospital services in Ireland.

Full text

Issue: Ir Med J; Vol 113; No. 1; P8
Counting the Toll of Smoking-Attributable Hospitalisations
A. Sheridan1, K.I. Quintyne2, P. Kavanagh3
On Behalf of the HSE Tobacco Free Ireland Programme
1. Tobacco Free Ireland Programme, Strategic Planning & Transformation, HSE
2. Department of Public Health, HSE North-East, Strategic Planning & Transformation, HSE
3. Health Intelligence Unit, Strategic Planning & Transformation, HSE
Abstract
Aim
In Ireland, 20% of adults smoke. Many current and ex-smokers live with ill-health and disability as a result of
smoking, and this study aimed to quantify the extent of smoking-related hospitalisations in Irish publicly-funded
hospitals.
Methods
A population attributable fractions approach was used in this analysis utilising smoking prevalence data from the
Healthy Ireland Survey and combining this with internationally-recognised relative-risks for current and past
smoking, and hospitalisation data and hospital base costs data sourced from HIPE, for the years 2011-2016.
Results
In 2016, there were 21,486 day case admissions, 33,615 inpatient hospital admissions consuming 309,117 bed days,
attributable to smoking and exposure to second-hand smoke, with an estimated cost of €172 million in publicly
funded hospitals. This represents 2% of day case admissions, 5% of inpatient admissions, and 8% of inpatient bed
days for that year.
Conclusion
Smoking continues to cause a considerable impact on hospital services in Ireland.
Introduction
Despite progress, tobacco consumption continues to cause a global epidemic of disability, ill-health and premature
death. Latest figures from the World Health Organization (WHO) report that 7 million people die each year as a
result of tobacco; more than 6 million of these deaths are as a direct result of smoking, with approximately 900,000
deaths among non-smokers as a result of exposure to second-hand smoke (SHS).1 In Ireland, in 2016, it is estimated
that almost 5,950 people died as a direct result of smoking with an additional 100 deaths estimated to be as a result
of exposure to SHS.2
In 2018, 20% of Irish adults (aged 15+ years) currently smoke, with slightly higher smoking rates reported among
males (22%) than females (17%).3 While there has been a reduction in smoking prevalence in recent years, continued
progress is required since Tobacco-Free Ireland, government policy on tobacco control, sets an ambitious target for
Ireland to be tobacco-free (smoking prevalence <5%) by 2025.4
It is over 50 years now, since the first studies detailing the causal relationships between smoking and ill-health were
published.5,6 Since then, this body of evidence on the health effects of smoking and exposure to second-hand smoke
has grown substantially with a causal relationship now established between smoking and nearly all organs of the
human body, and to foetal harm. 7 Population Attributable Fraction (PAF) methods, which assess public health

impact relative to the risk associated with the exposure and the prevalence of exposure in the population, can be
useful for reporting the burden of ill-health due to modifiable risk factors, such as smoking.8 In England, for example,
National Health Service (NHS) Digital and Public Health England (PHE) regularly report on national and local smoking
attributable hospitalisations to support health policy and planning.9,10
This study aimed to estimate hospitalisations and associated direct costs for conditions attributed to smoking and
exposure to SHS in Irish publicly funded hospitals in 2016, as well as some comparisons over a six-year period to
2011.
Methods
Standard epidemiological procedures for PAF estimation are well-described and were applied in this study,11, 12 and
are similar to previously published studies of smoking attributable burden in Ireland.13
Firstly, disease-specific Irish PAFs for smoking were calculated using the formula below:
a = smoking population attributable fraction
Pcur = proportion of current smokers Pex = proportion of ex-smokers
Rcur = relative risk for current smokers Rex = relative risk for ex-smokers
The data sources were age- and gender-specific prevalence of current- and ex-smoking sourced from the Healthy
Ireland Survey14, combined with international gender-specific relative risks for current and ex-smokers for health
conditions where a causal relationship with smoking has been established, see Table 1.7, 15
Secondly, the PAF for exposure to SHS for never smokers was derived using 2-step formula below:
B = Exposure to SHS PAF for each disease
Pshs = Proportion of non-smoking population exposed to SHS
Rshs = Relative risk for people exposed to SHS
NSB =Burden to non-smokers
T = Total number
The data source for exposure of SHS in the home (18%) was sourced from the Healthy Ireland Survey 2016 16 and
combined with internationally-recognised relative risks for non-smokers for health conditions where a causal
relationship with exposure to SHS.7

Table 1: Relative risk ratios for diseases for current and ex-smokers by gender
Health conditions with a causal relationship with smoking
Condition
ICD-10 Code
Age
Relative Risks
Source
Males
Females
Current
Ex-smoker
Current
Ex-smoker
CANCERS
Trachea, Bronchus, Lung
C33-C34
35+
23.26
8.70
12.69
4.53
Ref: 15
Oral and upper respiratory
C00-C14
35+
10.89
3.40
5.08
2.29
Ref: 15
Oesophageal
C15
35+
6.76
4.46
7.75
2.79
Ref: 15
Larynx
C32
35+
14.60
6.34
13.02
5.16
Ref: 15
Stomach
C16
35+
1.96
1.47
1.36
1.32
Ref: 15
Kidney
C64-C66
35+
2.50
1.70
1.40
1.10
Ref: 15
Cervical
C53
35+
-
-
1.59
1.14
Ref: 15
Bladder
C67
35+
3.27
2.09
2.22
1.89
Ref: 15
Pancreatic
C25
35+
2.31
1.15
2.25
1.55
Ref: 15
Leukaemia
C91-C96
35+
1.80
1.40
1.20
1.30
Ref: 15
Liver
C22
35+
1.70
1.40
1.70
1.40
Ref: 7
Colorectal
C18-C20
35+
2.14
1.47
2.14
1.47
Ref: 7
Unspecified area
C80
35+
4.40
2.50
2.20
1.30
Ref: 15
CARDIOVASCULAR
CONDITIONS
Coronary heart disease (CHD)
I20-I25
35-54
4.2
2.0
5.3
2.6
Ref: 15
55-64
2.5
1.6
2.8
1.1
Ref: 15
65-74
1.8
1.3
2.1
1.2
Ref: 15
75+
1.4
1.1
1.4
1.2
Ref: 15
Cerebrovascular Disease
I60-I69
35-54
4.4
1.1
5.4
1.3
Ref: 15
55-64
3.1
1.1
3.7
1.3
Ref: 15
65-74
2.2
1.1
2.6
1.3
Ref: 15
75+
1.6
1.1
1.3
1.0
Ref: 15
Aortic Aneurysm
I71
35+
6.21
3.07
7.07
2.07
Ref: 15
Atherosclerosis
I70
35+
2.44
1.33
1.83
1.00
Ref: 15
Other Arterial Disease
I72-I78
35+
2.07
1.01
2.17
1.12
Ref: 15
Other Heart disease
I00-I09, I26-I51
35+
1.78
1.22
1.49
1.14
Ref: 15
RESPIRATORY
CONDITIONS
Chronic obstructive pulmonary disease
J40-43, J47
35+
17.10
15.64
12.04
11.77
Ref: 15
Chronic airway obstruction
J44
35+
10.58
6.80
13.08
6.78
Ref: 15
Pneumonia
J12-J18
35-64
2.50
1.40
4.30
1.10
Ref: 15
65+
2.00
1.40
2.20
1.10
Ref: 15
Influenza
J10-J11
35-64
2.50
1.40
4.30
1.10
Ref: 15
65+
2.00
1.40
2.20
1.10
Ref: 15
Mycobacterium Tuberculosis
A15-A19
35+
2.30
-
2.30
-
Ref: 7
REPRODUCTIVE
CONDITIONS
Foetal death and stillbirths
P95, Z37.1, Z37.3,
Z37.4, Z37.6,
Z37.7
All Ages
-
-
1.47
-
Ref: 7
Ectopic pregnancy
O00
All Ages
-
-
1.91
-
Ref: 7
Erectile dysfunction
F52.2, N48.4
20+
1.7
1.6
-
-
Ref: 7
Oral clefts
Q35-Q37
<1 yr
-
-
1.28
-
Ref: 7
Perinatal effects
P00.0 - P77
(selection)
All Ages
-
-
1.50
-
Ref: 7
Low birth weight
P07
<1 yr
-
-
1.40
-
Ref: 7
OTHER
CONDITIONS
Cataract
H25
45+
1.54
1.11
1.54
1.11
Ref: 15
Macular degeneration
H35.3
45+
2.97
1.88
2.97
1.88
Ref: 7
Hip #
S72.0-S72.2
55-64
1.17
1.02
1.17
1.02
Ref: 15
65-74
1.41
1.08
1.41
1.08
Ref: 15
75+
1.76
1.14
1.85
1.22
Ref: 15
Peptic ulcer disease
K25-K28
35+
5.40
1.80
5.50
1.40
Ref: 15
Periodonitis
K05.2-K05.6
35+
3.97
1.68
3.97
1.68
Ref: 15
Diabetes (Type 2)
E11
35+
1.37
1.14
1.37
1.14
Ref: 7
Rheumatoid arthritis
M05-M06
35+
1.89
1.25
1.75
1.25
Ref: 7
Dental caries
K02
ALL
1.76
1.39
1.76
1.39
Ref: 7
Crohn's disease
K50
35+
2.10
1.0
2.10
1.0
Ref: 15
Low bone density
M80-M83
45+
-
-
1.25
-
Ref: 7
Health conditions with a causal relationship with exposure to second-hand smoke
Condition
ICD-10 Code
Age
Relative Risk
Source
Lung (SHS)
C34
20+
1.29
Ref: 7
CHD (exposure to SHS)
I20-I25
20+
1.32
Ref: 7
Stroke (exposure to SHS)
I63
20+
1.25
Ref: 7
SIDS
R95
<1
1.94
Ref: 7
Middle ear disease (exposure to SHS)
H65-H75
0-10
1.32
Ref: 7
Low Birth weight (exposure to SHS)
P07
-
1.20
Ref: 7

The smoking PAFs were then applied to observed numbers of in-patients, day cases and associated bed days, by
condition, with a primary diagnosis of conditions which can be caused by smoking for the years 2011 to 2016
sourced from the Hospital In-Patient Enquiry System (HIPE).17 While, the PAF for exposure to SHS for each condition
was applied to the non-smoking health burden to estimate the number of hospitalisations due to exposure to SHS.
Finally, the average base costs for inpatient and day case admissions for 2016, were sourced from the Healthcare
Pricing Office (HPO) through personal communication. These unit costs (inpatient admission = €4,602 and day case
admission = €765) were then applied to the estimated numbers of smoking and SHS-attributable hospitalisations and
totalled for the year 2016.
All calculations were carried out using Microsoft Excel 2007.
Results
The PAF for all conditions included in this analysis by gender and by disease group, in an Irish setting, are displayed in
Figure 1. By individual condition, chronic obstructive pulmonary disease (COPD) was the condition with the highest
PAF for both males (90.1%) and females (84.3%). Two other conditions had a PAF greater than 80% in males; cancer
of the lung, trachea & bronchus (88.8%), and cancer of the larynx (83.5%). There were no additional conditions with
a PAF greater than 80% among females. Males had higher PAFs than females for most conditions, with the exception
of: Coronary heart disease (35-54 year olds); Cerebrovascular diseases (<75 year olds); Pneumonia (<65 year olds),
Influenza (<65 year olds), and pancreatic cancer (35+ year olds). See Figure 1 (Next page)..

Figure 1: Irish Population Attributable Fractions for smoking & exposure to SHS, 2015
Sources: HPO and HSE calculations
0% 20% 40% 60% 80% 100%
Low bone density_age45+
Crohn's disease_age35+
Dental caries_all ages
Rheumatoid arthritis_age35+
Diabetes (type 2)_age35+
Periodonitis_age35+
Peptic ulcer disease_age35+
Hip#_age75+
Hip#_age65-74
Hip#_age55-64
Macular degeneration_age45+
Cataract_age45+
Low birth weight_<1year
Perinatal effects_all ages
Oral clefts_<1year
Erectile dysfunction_age20+
Ectopic pregnancy_all ages
Foetal death & stillbirths_all ages
Mycobacterium Tuberculosis_age35+
Influenza_age65+
Influenza_age35-64
Pneumonia_age65+
Pneumonia_age35-64
Chronic airway obstrutive disease_age35+
COPD_age35+
Other heart disease_age35+
Other arterial disease_age35+
Atherosclerosis_age35+
Aortic Aneurysm_age35+
Cerebrovascular disease_age75+
Cerebrovascular disease_age65-74
Cerebrovascular disease_age55-64
Cerebrovascular disease_age35-54
Coronary heart disease_age75+
Coronary heart disease_age65-74
Coronary heart disease_age55-64
Coronary heart disease_age35-54
Unspecified area_age35+
Colorectal_age35+
Liver_age35+
Leukaemia_age35+
Pancreatic_age35+
Bladder_age35+
Cervical_age35+
Kidney_age35+
Stomach_age35+
Larynx_age35+
Oesophageal_age35+
Oral and upper respiratory_age35+
Lung, Trachea & Bronchus_age35+
Other Effects
Reproductive
Conditions Respiratory Diseases Cardiovascular Disease Cancers
Population Attributable Fraction (PAF)
Female
Male

Applying these PAFs to Irish hospital activity data in 2016, there were an estimated 33,615 inpatient hospital
admissions and 21,486 day case admissions attributable to smoking and exposure to SHS in 2016. See Table 2 Across
all hospital activity in these hospitals in 2016, this represents 5% of inpatient admissions and 2% of day case
admissions, and resulted in 309,117 bed days (8% of all inpatient bed days in 2016).
Table 2: Hospital activity 2016 for those with a primary diagnosis of diseases which can be caused by smoking and exposure to
SHS
Conditions caused by
smoking
Inpatient admissions
Day cases
Bed days
Male
Female
Male
Female
Male
Female
Cancers
3,713
1,898
5,226
2,614
48,147
23,895
Cardiovascular conditions
6,979
2,749
2,234
815
54,105
23,238
Respiratory conditions
8,105
7,563
585
668
68,086
61,767
Reproductive conditions
<5
849
27
12
11
10,937
Other conditions
682
692
4,432
4,661
6,997
8,267
Total (Smoking)
19,481
13,751
12,504
8,770
177,346
128,104
Conditions caused by
exposure to SHS
Inpatient admissions
Day cases
Bed days
Male
Female
Male
Female
Male
Female
Lung Cancer
4
7
4
10
41
79
Coronary heart disease
150
73
71
37
776
395
Stroke
40
39
0
0
671
708
Middle ear disease
13
10
54
36
24
19
Low birth weight
0
49
0
0
0
955
Total (SHS)
207
178
129
83
1,512
2,156
TOTAL (Smoking & SHS)
Inpatient admissions
Day cases
Bed days
33,615
21,486
309,117
Sources: HPO and HSE calculations
Table 2 details these smoking and SHS-related hospitalisations in 2016 by gender and disease group. Almost 60% of
both these inpatient admissions (n=19,688) and day case admissions (n=12,633) were by males. Overall, the burden
of smoking and SHS-related hospitalisation is greater for males than females, with 7% of all hospitalisations among
males estimated to be smoking or SHS-related, compared to 4% among females.
Further analysis of these hospitalisations revealed that respiratory conditions (47%, n=15,668) were the most
common reason for smoking-related inpatient hospitalisation in 2016 followed by cardiovascular conditions (29%,
n=9,728) and cancers (17%, n=5,611). ‘Other conditions’ (43%, n=9,093) were the main reason for smoking-related
day case admission, followed by cancers (37%, n=7,840) and cardiovascular conditions (14%, n=3,049). Coronary
heart disease was the most common reason for SHS-related inpatient hospitalisation (58%, n=223) and SHS-related
day case admission (51%, n=108). Using the estimates in Table 2, almost one-in-five inpatient admissions for all
respiratory diseases, circulatory diseases and cancers in 2016, were estimated to be attributable to smoking and
SHS.
Figure 2 displays the trend in inpatient and day case admissions attributable to smoking and exposure to SHS from
2011-2016; the number of these admissions increased by 13% (9% increase in all inpatient activity) and 22% (20%
across all day case activity), respectively, as displayed in Figure 2. However, tests for trends revealed that these
increases were not significantly different to increases in overall hospital activity for the same period. Compared to
2011, the number of smoking-related inpatient bed days decreased marginally by <1% in 2016.

Figure 2: Estimated number of hospital admissions with a primary diagnosis of diseases which can be attributable to smoking
and exposure to SHS, 2011-2016.
Sources: HPO, HSE
Finally, using the average base costs in 2016, the estimated direct cost of smoking & SHS-related hospitalisations
detailed in this analysis was €171.5 million in 2016.
Discussion
This study presents an up-to-date estimate of the burden of smoking and SHS-related hospitalisations in Ireland to
2016; the number of hospitalisations increased yearly, as did all hospital activity, and in 2016 there were an
estimated 33,600 inpatient admissions and 21,500 day case admissions at a total cost (direct) of approximately
€171.5 million. It must be noted that this is an under-estimate due to the exclusion of outpatient clinic attendances
or emergency department presentations, and this analysis also only documents those admissions with a primary
diagnosis of the disease; many of these patients are on a long journey to recovery, for example, cancer patients, and
will have several more hospital encounters for treatment etc, however for comparison reasons, this analysis detailed
primary diagnosis only. Nevertheless, for a health system that is currently experiencing many challenges regarding
capacity, waiting times and waiting lists, the fact that this many hospitalisations are potentially preventable is
certainly food for thought!
In 2018, 20% of Irish adults smoke, with high smoking rates among young people; this compares favourably to a
smoking prevalence of 29% in 2007 3,18. And, while smoking prevalence is falling and will continue to, in the attempt
to achieve a smoke-free Ireland by 2025, many people will continue to live with the health effects of their smoking
into the future. A recent Irish study detailed the impact of smoking on the health of older Irish adults: those who
smoked self-reported poorer physical and mental health, and considered their own health to be worse than their
peers; In addition, the prevalence of self-reported smoking-related chronic diseases was highest among ex-smokers,
and the extent of this ill-health was related to the amount smoked.19 Quitting smoking results in many physical and
mental health gains; specifically, reduced risk of death from cardiovascular disease and COPD, and stopping smoking
before age 40 reverts life expectancy close to that of non-smokers.20 So, in order to maximise the benefits of
quitting smoking, smokers must quit at a younger age.
An interesting finding of this study is the greater burden of smoking-related disease for males, with almost 50% more
hospitalisations by males compared to females. The recent State of Tobacco Control in Ireland report detailed how
the impact of tobacco in Ireland is different for males in Ireland, with differences in smoking behaviour, the use of
smoking cessation services, and the burden of smoking-related disease and death.2 Irish males smoke more than Irish
females (22% versus 17%), however, quitting intentionality, and the proportion of quit attempts among males is
similar to female rates.3
Successfully quitting smoking is difficult, and currently the majority of smokers attempting to quit choose to use no
supports (42%), or use e-cigarettes (41%) in their quit attempt.3 Research indicates that smokers are twice as likely
to quit if they engage with a smoking cessation service, such as the HSE QUIT service (a team of advisors available to
17,587
19,642 20,068 20,561 20,723 21,486
30,122 31,859 32,119 32,210 32,510 33,615
0
5,000
10,000
15,000
20,000
25,000
30,000
35,000
40,000
2011 2012 2013 2014 2015 2016
Number
Day Case Admissions Inpatient Admissions

smokers over the phone, by email, online, or in person), and they are four times more likely to quit if they also use
smoking cessation medications, such as varenicline, bupropion and nicotine replacement therapy.21 Internationally, a
large body of evidence supports the delivery of smoking cessation interventions in all healthcare encounters.22-24
Currently in Ireland, national clinical guidelines for the identification and treatment of tobacco addiction are in
development and have been approved for prioritisation by the Department of Health’s National Clinical Effectiveness
Committee (NCEC). This guideline will utilise the Department of Health commissioned Health Technology
Assessment (HTA) of smoking cessation treatments available in Ireland by the Health Information & Quality
Authority (HIQA), 21 as well as other International guidelines on smoking cessation, with planned publication of the
guideline in late 2019. Evidence-based smoking cessation is key to Ireland becoming tobacco-free by 2025.
Winning the war on tobacco is a long game, and for health policy-makers and planners, continued focus on this area
competes with other priorities. Regular reporting of the burden of ill-health due to amenable risk factors,
highlighting the impact on health services and costs, can be an important way of sustaining engagement.25 The
utilisation of PAF methodology allows for comparisons internationally and provides robustness to the evidence; the
automation of such analysis would allow for more routine, timely reporting.
Some limitations to this study were noted by the authors: Firstly, only those conditions with a causal relationship
with smoking and exposure to SHS were included; secondly, attendances at outpatient clinics and emergency
departments were excluded as there are no reporting systems, and thirdly, only hospital admissions with a primary
diagnosis of these conditions was reported in this analysis; this is as per the methodology for this type of analysis,
and for comparison reasons, it is necessary to follow the same methodology as other organisations, internationally.
In conclusion, almost 1,000 hospital episodes each week in Irish hospitals are attributable to smoking and exposure
to SHS; with one-in-five admissions for respiratory diseases, circulatory diseases, and cancers potentially
preventable. This analysis highlights the impact of tobacco on Irish adults, especially males. For the health services,
this analysis highlights the potential savings if Ireland was tobacco-free and the significant opportunities to engage
with smokers with evidence-based smoking cessation.
We wish to acknowledge the Healthcare Pricing Office, HSE for providing access to the HIPE dataset and the
Department of Health for providing access to the Healthy Ireland Survey 2015 research file.
Declaration of Conflicts of Interest:
The authors have no conflicts of interest to declare.
Corresponding Author:
Aishling Sheridan,
HSE Tobacco Free Ireland Programme
Email: aishling.sheridan@hse.ie
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