Economic Burden of Self-Reported Tobacco Smoking Compared with Non-Smoking: Systematic Review and Meta-Analysis of Direct Health Care Costs

Background

Tobacco smoking remains a global public health challenge, contributing to preventable mortality and morbidity and imposing substantial burdens on health care costs. We investigated whether direct health care costs differ substantially between self-reported tobacco smokers and non-smokers.

Methods

This systematic literature review was conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Medline PubMed, Embase, PubMed Central, and Scopus were searched to identify studies of direct health care costs between smokers and non-smokers for participants aged ≥18 years. All observational, prospective, retrospective, and non-randomized comparative studies were considered. Data extraction included mean annual health care costs (± SD) for both groups. Mean differences (MD) in annual health care costs between smokers and non-smokers, expressed in 2025 US dollars, were compared and adjusted for a 12-month period and inflated to 2025 using consumer price indices.

Results

Of 873 studies identified, 11 were included in quantitative synthesis, which compared 19,759,529 smokers with 206,913,108 non-smokers for direct health care costs. Mean age ranged from 34.5–60.6 years for smokers and 34.3–65.1 years for non-smokers. Mean annual health care costs ranged from $65,640–$1297.1 for smokers and $54,564–$724.4 for non-smokers. Annual incremental direct health care costs for smokers versus non-smokers ranged from –$458 (95% CI [confidence interval]: –2011.0 to 1,095.0) to $11,076 (95% CI: 10,211.9 to 11,940.1) in 2025 US dollars. Meta-analysis revealed smoking generally incurred greater health care costs than non-smoking, with a mean annual incremental cost of $1916.5 (95% CI: –439.9 to 4,272.9). The result was not statistically significant (MD = 1,916.5; p = 0.111). Substantial heterogeneity was observed (I² = 99.9%). Sensitivity analysis excluding studies of chronic disease yielded a reduced incremental cost for the general population, with a statistically significant difference (MD = 583.9, p = 0.02), although heterogeneity remained high (I² = 98.0%).

Conclusion

This meta-analysis supports the assertion that smoking substantially increases direct health care costs compared with non-smoking, particularly for the general population.