Annotated Bibliography

Anderson LH, Martinson BC, Crain AL, Pronk NP, Whitebird RR, Fine LJ. (2008). Health care charges associated with physical inactivity, overweight, and obesity. Prev Chronic Dis, 5(2), 1-12. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1435706/.

The authors of this journal article are a team of researchers and health science professors from the University of Amsterdam. Anderson, Crain and Whitebird each have a PhD in biology, while Martinson and Fine have a PhD in computer technology. The article discusses the health care costs associated with individuals who are physically inactive, overweight, obese and healthy as well as whether or not the prevention of obesity and smoking will either increase or decrease the costs for the Netherlands population. It was predicted that a decrease in health care costs would result from the effective prevention of smoking and obesity. The authors concluded that although effective obesity and smoking prevention reduces the costs of obesity-related diseases, this reduction is offset by the increased costs of diseases unrelated to obesity that occur during the extra years of life gained by slimming down. The data for this study was gathered first through primary research as surveys were distributed to 500 men and 500 women to obtain their personal information including their weight, body mass index, age and health status (i.e. smoker, obese, healthy). Afterwards, these results were inputted to the National Institute for Public Health and the Environment chronic disease computer model. This was used to calculate yearly and lifetime medical costs associated with obesity and smoking in The Netherlands. All input parameters of the simulation model were based on the data collected from the obese, smoking and healthy Netherland citizens as well as the assumed trends of health care uses and costs. The researchers used this model to estimate the number of surviving obese and smoking individuals and the occurrence of various diseases for three hypothetical groups of men and women, which was done by examining data from the age of 20 until the time when the model predicted that everyone had died. This study refutes the thesis that obese and smoking individuals should pay a health care premium as it states that a larger percentage of health care costs are a result of the long life span of healthy individuals as oppose to the short life span of smoking and obese individuals. In other words, it suggests that healthy individuals are the primary reason behind the rising health care costs. This study has many limitations. To begin, the results that were gathered were almost completely based on estimates calculated by a computer model. By no means is relying on computer technology to estimate results, a 100% accurate way to collect data. Additionally, the authors assumed that costs per patient for each risk factorrelated disease are equal. This similarity might not always be the case. For instance, treatment costs for lower-back pain could depend on body mass index (BMI) status. Lastly, it was concluded that obesity and smoking increases the risk of diseases such as diabetes, coronary heart disease, and cancer thereby increasing health-care utilization but decreasing life expectancy. However, the successful prevention of obesity and smoking, in turn, increases life expectancy. What was not taken into consideration was the fact that these life-years gained from the individual who lost weight or gave up smoking are not lived in full health and come at a price: people suffer from other diseases, which increase health-care costs. However, because of differences in life expectancy (life expectancy at age 20 was 5 years less for the obese group, and 8 years less for the smoking group, compared to the healthy-living group), total lifetime health spending was greatest for the healthy-living people, lowest for the smokers, and intermediate for the obese people.

Field, J., McCombs, J., & Sengupta, N. (2010). Pnp23: The Impact Of Alcohol Consumption And Smoking On Short-Term Healthcare Costs In A Managed Care Population. Value in Health, 2(3), 177177. Retrieved from http://www.valueinhealthjournal.com/article/S1098-3015(11)70948-2/abstract. All three authors are professors from the University of Southern California School of Pharmacy and

researchers for the Department of Pharmaceutical Economics and Policy in Los Angeles, California. The purpose of this article was to discuss and quantify the extent to which, future short-term healthcare costs are impacted by current alcohol consumption and smoking in California. It was hypothesized that both health conditions would continue to have a significant impact on the rising healthcare costs in the future of the state of California. Results from this analysis concluded that alcohol consumption would reduce short-term health care costs in the future. Alcohol consumption decreased health care costs by 0.93%. Furthermore, it was concluded that smoking was not found to affect future costs at all. In 2010, only 11.9 percent of people in California smoked, leaving California second only to Utah in having the lowest smoking rate in the country. Primary research was conducted through surveying and collecting data from a random sample of 12,185 adult patients from the Kaiser Permanente Patient Consultation Study. After this, by using multivariate predictive models, the logarithm of total healthcare costs over 2 years was regressed on patient- specific demographic and health status variables. This article refutes the thesis which sates that obese and smoking individuals should pay a healthcare premium because it concludes that smoking will have no effect on the future health care costs. This study does have flaws. To begin, the population of California is generalized. Not all smokers and problem drinkers in the state are exactly like the individuals from the Kaiser Permanente Patient Consultation Study. In other words, a random sample of participants was not chosen for his study. In fact, a sample of participants was explicitly chosen to represent the population of California. Additionally these patients are recovering from their unhealthy habits, therefore requiring less medical attention than someone who is continuing to smoke, is consistently having operations/surgeries and is constantly requiring numerous prescribed medications to remain alive. Lastly, trends in health care costs and health care use were incorporated in a mathematical model to determine the results of the future. Trends change day by day and by no mean do they remain constant for long periods of time. The future can be predicted with these mathematical models, however they are simply estimates. Man, W. (2011). The Cost of obesity. Master of Public Health , 2(1), 67. http://edoc.sub.unihamburg.de/haw/volltexte/2012/1615/pdf/lsab12_28.pdf. Weiyie Man is a population researcher who has a Master in Health Economics, Policy Law (HEPL). This article seeks to answer the question concerning whether the increase of health-related diseases and conditions due to obesity is resulting in an overall increase or decrease the American health care costs. The author predicted that the rise in obesity-related diseases is the reason for which health care costs are increasing. The author concludes that due to increasing cases of obesity and therefore, rising diseases and conditions that must be treated with medical attention, the nations health care costs are skyrocketing. On average, health care costs for obese people are 42 percent higher than normal weight people. Through secondary research, Man uses results and findings from other academic journal articles and experiments. This article supports the thesis that obese individuals should pay a health care premium for their lifestyle choices, however it provides no proof that smokers should pay a premium cost. The study proves that the healthcare costs of obese individuals are significantly greater than those of healthy individuals, resulting in the rising of medical costs in the United States. This benefits the thesis mentioned previously because the more healthcare resources that are required by the obese American population, the greater the increase in medical costs for the population will be since the advanced technology and rising number of medical professionals depends upon the government to pay more money. In the end, it all comes down to raising the medical costs for every citizen, which would be prevented if only the smoking and obese individuals paid a premium healthcare cost. The lifetime medical costs related to diabetes, heart disease, high cholesterol, hypertension, and stroke among the obese are $10,000 higher than among the non-obese. The most recent study, conducted in 2009, estimated that obesity-related direct medical costs total $147 billion annually in the United States, which corresponds to 9.1 percent of annual medical spending.

Man, W. (2007). The lifetime healthcare costs of unhealthy behaviour . Erasmus Rotterdam, 3(2), 132. Retrieved from http://www.google.ca/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=0CDA QFjAA&url=http%3A%2F%2Fthesis.eur.nl%2Fpub%2F4372%2FManW.pdf&ei=71eiUuvkC6bI2AXg24F I&usg=AFQjCNEdE1mXxcKDM2sgzQIp03Z372doLQ&sig2=zbnd7_tuOrPBtMhEp55BVw&bvm=bv.577 52919,d.b2I Weiyie Man in a population researcher who has a Master in Health Economics, Policy Law (HEPL). The aim of this study was to examine the question of whether effective prevention of smoking and obesity leads to lower health care costs for health insurers. Man hypothesized that a decrease in these costs would result from obesity and smoking prevention. He concluded that in the short run, effective prevention of unhealthy behaviour leads to lower health care costs for a health insurer. Through secondary research, data from the Cost of Illness study (COI) in the Netherlands in 2003 was used as well as the Chronic Disease Model (CDM) to estimate the health care costs of diseases related to obesity and smoking. This study supports the thesis that obese and smoking individuals should pay a healthcare premium as it provides and explains a negative impact on the Canadian population that is a result of the unhealthy lifestyles. This impact involves the increase in healthcare costs for every Canadian citizen. Unhealthy behaviour leads to acute and chronic diseases, in turn leading to care consumption, which eventually would result in high health care costs. A limitation for this study is that the data used from the Netherlands study is outdated as it is from 2003. It is likely that these results could be different if the data was collected in 2007 (when the article was written an published). Secondly, the results of this study only apply to the Netherlands health insurance system. Health insurance systems differ strongly among countries. Approximately 370billion direct medical costs are associated with obesity and smoking in 2007 in Canada. Max, W., Rice, D. P., Sung, H., Zhang, X., & Miller, L. (2008). The Economic Burden Of Smoking In California. Tobacco Control, 13(3), 264-267.

All of the authors are professors of Health Economics, each at a different university: Stanford University, University of Berkeley, University of Los Angeles, University of San Diego and University of Southern California. Wendy Max, the lead author and researcher is also co-director of the Institute for Health & Aging at the University of San Francisco. The purpose of this study was to gather data concerning the direct and indirect costs of smoking for California. Direct costs included hospitalizations, ambulatory care, prescription drugs, home health care, and nursing home services and indirect costs included lost productivity in the workforce due to smoking related illnesses. It was predicted that was that these costs would have decreased from 1999 since cigarettes have increased in price and since smoking had been banned from bars and various other public places such as restaurants. The authors concluded that the public health impact of cigarette smoking in California is enormous and is increasing in terms of the large number of preventable illnesses, premature deaths, and high health care costs and productivity losses. Currently in 2008, the total costs of smoking in California are $15.9 billion, $475 per resident, and $3331 per smoker. Direct costs were $8.6 billion (54% of the total), indirect costs due to lost productivity from illness were $1.5 billion (10%), and indirect costs due to premature deaths were $5.7 billion (36%). Primary research and resources were gathered for this study. A survey was conducted to retrieve the smoking statuses, ages, sexes and ethnicities of a sample population. Secondary research was done through the research of academic studies on trends of medical professional uses and costs, deaths and rates of unemployment due to smoking-related diseases. This data was then used in econometric models to estimate the smoking attributable fraction (SAF) for direct costs and indirect costs due to lost productivity from smoking related illness. The models were controlled for socioeconomic factors and other risk behaviours in order to generate accurate values for direct and indirect costs in terms of dollars and cents. Additionally, this model was used by various other states for many population studies. This study partly supports the thesis that smokers and obese people should pay a healthcare premium for their lifestyle,

because it only brings the effects of smoking into focus. The results are beneficial to the smoking portion of the thesis as they prove that not only are health care costs skyrocketing due to the act of smoking, but many other direct and indirect cost as well, such as welfare or disability support covered by the government due peoples inability to work. In turn, taxes for the entire California population are increasing to compensate for these governmental dispenses. Limitations are always involved with using model to form estimates, however these models were controlled for socioeconomic factors and other risk behaviours, therefore being fairly accurate. MM, F. (2001). Obesity, cigarette smoking and the cost of physicians' services in Ontario. Europe Pub Med Central, 2(23), 1.

Dr. Murray Finkelstein is the Department of Family & Community Medicine assistant professor & clinician investigator at the University of Toronto and is an assistant professor at McMaster University. While attending McGill University, he received a Masters in health sciences and a PhD in physics. Finkelsteins journal article discusses whether or not there is a direct relationship between the cost of physicians' services in Ontario and the body mass index (BMI) of individuals as well as if there is a direct relationship between the cost of physicians' services in Ontario and every year of daily smoking in the Netherlands. It was hypothesized that there is in fact a direct relationship between the BMI of individuals and physician services as well as between daily smoking and medical costs from physician services; as one increases, the other will as well. The author concludes that overweight and smoking individuals are responsible for large costs to the health care system. Additionally, an increase in the BMI of an obese individual or the act of smoking on a daily bases directly increases physician attention and therefore medical costs. Through primary research, Finkelstein distributed surveys to 2170 Ontario residents in the mail. This articles approves the thesis that a more expensive health care premium should be made an obligation to those who are obese or those who smoke because in terms of obesity the results show that every little increase in the body mass index (BMI) results in a drastic increase the health care costs of the entire population. Additionally, in terms of smoking, the results show that for every year of daily smoking there is also an increase in health care costs; it is not as drastic, however it does exist and does contribute to the rising costs. The annual attributable cost of smoking and overweight among residents of Ontario, aged 4079, was estimated at $275,000,000. The mean per capita cost of physicians' services in Ontario increased by $8.90 (95% CI: $1.90-$15.60) for each unit increase in BMI and by $1.75 (95% CI: $0.11-$3.40) for every year of daily smoking. Rashad, I., Grossman, M. (2004). The Economics of Obesity. Public Interest, 12(4), 104-112. Retrieved from http://mres.gmu.edu/pmwiki/uploads/Main/e2read.pdf. Inas Rashad is an associate professor of economics at Queens College of the City University of New York and a research associate for the health economics program at the National Bureau of Economic Research. Michael Grossman is an American health economist and economics professor at City University of New York Graduate Center. The authors hypothesis is that the increase in obesity world - wide is largely due to the genetic component of the health condition that plays the role in determining why a given individual is obese. It is concluded that the explosive growth fast-food restaurants is what mainly fuels the obesity epidemic. As much as two-thirds of the increase in adult obesity since 1980 can be explained by the rapid growth in the per capita number of fast-food restaurants. Secondly, it was concluded the inflation of cigarette prices is the second most important factor that contributes to the abundance of obese individuals because higher cigarette taxes ad higher cigarette prices have caused more smokers to quit but these smokers have begun eating more as a result. Each 10% increase in the real price of cigarettes, produces a 2% increase in the number of obese people. Through secondary research, information and data

was gathered from other academic journals and experiments. The results from this study greatly benefits the thesis that obese individuals should pay a health care premium, however the portion of he thesis that states that smokers should pay this same surcharge is not supported because the study solely focuses on obesity. If high prices in food is preventing obese individuals from buying them, then an additional health care charge would be necessary to force the individuals to change their lifestyles. Additionally, inflation caused smokers to quit therefore, an increase in health care costs for obese people could result in them quitting their habits. Lastly, an increase in healthcare costs for obese individuals no longer seems as unethical as some may say since it is proven that the condition is a lifestyle choice as oppose to something that someone is born with.

Sturm, R. (2002). The Effects Of Obesity, Smoking, And Drinking On Medical Problems And Costs. Health Affairs, 21(2), 245-253. Retrieved from http://content.healthaffairs.org/content/21/2/245.

Roland Sturm is a senior economist at the RAND Corporation and a professor at the Pardee RAND Graduate School, where he teaches advanced econometrics. He has testified before the U.S. Senate, House of Representatives, and state legislatures. Sturm received an M.S. in economics from the University of Florida, an M.A. in statistics and a Ph.D. in economics from Stanford University. This article compares the effects of obesity, smoking, and problem drinking on Canadian health care use and health care costs in terms of dollars and cents. It brings attention to the fact that obesity in particular, appears to have a stronger association with the occurrence of chronic medical conditions, reduced health-related quality of life, and increased health care and medication spending than smoking or problem drinking has. Nevertheless, the latter two groups are increasing in prevalence and have received more consistent attention from medical professionals compared to healthy Canadian individuals. Sturm concludes that the cost effects of obesity on medication are significantly larger than the effects of daily smoking or problem drinking, thus Canadian health care costs are rising. This article supports the thesis that suggests that smoking and obese individuals should pay a health care premium for their choices in order to lower the health care costs of the Canadian population because it proves that smoking and obesity are primary drivers of health care spending. Through primary research, Sturm conducts a national household telephone survey involving Canadian men and women between the ages of eighteen and sixty-five who are of various health statuses and races. Obesity is associated with a 36 percent increase in inpatient and outpatient spending and a 77 percent increase in medications, compared with a 21 percent increase in inpatient and outpatient spending and a 28 percent in- crease in medications for current smokers and smaller effects for problem drinkers. In terms of absolute changes in costs for in- patient and ambulatory care (which probably understate true absolute effects because of underreporting), obesity is associated with an average increase of $395 per year, overweight with an increase of $125, current or ever smoking about $230, problem drinking with $150, and aging with $225. The only limitation to Strums research is that as a senior economist who grew up in a society that values traditional social norms, the authors perspective on obesity and smoking is slightly skewed because obesity and chain-smoking deviate against past societal expectations.