The lifetime health and economic burden of smokeless tobacco use in Bangladesh, India and Pakistan:results from ASTRAMOD

Introduction: Under the current policy landscapes, the lifetime health and economic burden of smokeless tobacco (ST) products, consumed by over 297 million ST users in South Asia, is unknown. The aim of this study was to estimate the lifetime health effects and costs attributable to current and future ST use in Bangladesh, India and Pakistan where the majority of ST users live. Methods: We developed a Markov-based state transition model (ASTRAMOD) to predict the lifetime costs of treatment of four diseases (oral, pharyngeal, oesophaegal cancers and stroke) and disability-adjusted life years (DALYs), attributable to the current and future use of ST under existing ST policy scenario. Country-specific Global Adult Tobacco Surveys (GATS), life tables and meta-analyses of South Asian and South East Asian studies were used to populate the model. A probabilistic sensitivity analysis evaluated the uncertainty in model predictions. Results: If there were no change in the current ST policies, the lifetime ST attributable treatment costs would be over US$19 billion in India, over US$1.5 billion in Bangladesh and over US$3 billion in Pakistan. For all countries, the attributable costs are higher for younger cohorts with costs declining with increasing age for those over 50. The model predicted that a typical 15-year old male child would gain 0.07-0.18 life years, avert 0.07-0.19 DALYs and generate a cost-savings of US$7-21 on healthcare spending if ST policies were changed to eliminate ST use. Conclusion: Policy interventions aimed at decreasing uptake of ST and increasing quitting success have the potential to substantially decrease the economic and health burden of ST.