Estimating the Economic Costs of the Abuse of Tobacco, Alcohol and Illicit Drugs: A Review of Methodologies and Canadian Data Sources
Bernard CK Choi, Lynda Robson and Eric Single

Abstract

The study of economic costs of substance abuse, namely, abuse of tobacco, alcohol and illicit drugs, can provide important information for setting good public health policies. This review paper provides a list of previous cost studies of substance abuse, compares the cost categories considered by various methodologies and describes an inventory of data sources for obtaining relevant information for cost studies. Investigators will find this paper useful as an introduction to the literature in this area, for designing a list of cost categories to consider in a particular study and for identifying relevant data sources.

Key words: Alcohol; Canada; data sources; drugs; economic cost; methodology; substance abuse; tobacco

Introduction

There is a need for estimates of the economic costs of substance abuse.^1-4 It has been well established that the use of alcohol, tobacco and other drugs involves a large number of adverse health and social consequences. In most countries, there is a specific national policy for the regulation of these psychoactive substances. Because the justification for special regulation is the economic and social costs, and also because economic policy instruments are used in the regulation of these substances, it makes good sense to have sound estimates of the economic costs of substance abuse.

This paper reviews and summarizes the methodologies suggested by a number of recently published papers in both the medical and economic literature on the costs of substance abuse. It provides concepts and background knowledge to investigators who are interested in estimating these costs.

For the purposes of this paper, substance abuse includes the excessive use of alcohol, tobacco and illicit drugs (ATD). Legal prescription drugs (pharmaceuticals) are not included. Abuse or misuse of pharmaceuticals is responsible for significant economic costs, but it is extremely difficult to obtain relevant information since very little research has been done on the abuse of prescription drugs.

The definition of substance abuse is rarely attempted in the literature, and those definitions that are available are not usually expressed in economic terms. Based on the definition of Collins and Lapsley,¹ our study defines substance abuse as any substance use that involves a net social cost additional to the resource costs of the provision of that substance. Thus, the costs include the complete set of problems associated with the use of psychoactive substances, rather than just those costs associated with physical dependence or heavy use.

Previous Studies Estimating Economic Costs of Substance Abuse

As there are many published cost studies, it would be beyond the scope of this paper to review and compare them one by one. Therefore, only recently published review articles that established methods of cost estimation are considered. We identified four such articles. Rice et al.⁵ devised a list of economic costs for alcohol and drug abuse and mental illnesses in the US. Collins and Lapsley¹ proposed a methodology to estimate the economic costs of drug abuse (ATD) in Australia. In another American setting, Manning et al.⁶ estimated the costs of poor health habits (smoking, drinking and sedentary lifestyles). Finally, French et al.⁷ suggested a conceptual framework to estimate the social costs of drug abuse.

We must point out that the last article⁷ was a theoretical paper and did not review or establish methods of cost estimation. However, we included it in our study because of its unique and innovative contributions to the different categories of costs, such as the concept of avoidance behaviour costs for families, communities and victims of crime in terms of educational and public service efforts and programs.

A list of the cost studies and pertinent theoretical papers reviewed by the four above-mentioned articles is given in Tables 1A, 1B and 1C sorted by substance (alcohol, tobacco or illegal drugs) and year of publication, and then by alphabetical order of authors. In addition, several cost studies not reviewed by those four articles were also included, having been identified in a literature search. The tables are intended to be a resource tool for researchers in this domain.

TABLE 1B Previous cost studies of alcohol, tobacco and illicit drugs reviewed by four major recent studies, or identified in literature search@: (B) TOBACCO
Author(s)	Year	R	C	M	F
Oakes et al.	(1974)60			X
Atkinson and Townsend	(1977)61			X
Luce and Schweitzer	(1978)11			X
WHO	(1979)62		X
Forbes and Thompson	(1982)63		X	X
Yach	(1982)64		X
Forbes and Thompson	(1983)65		X	X
Kristein	(1983)66		X	X
Leu and Schaub	(1983)67			X
Rice and Hodgson	(1983)68			X
Warner	(1983)69		X
Collishaw and Myers	(1984)70		X
Leu	(1984)71			X
Oster et al.	(1984)72		X	X
Leu and Schaub	(1985)73			X
Ockene	(1985)74		X
Office of Technology Assessment	(1985)75			X
Sachs	(1985)76		X
Vogt and Schweitzer	(1985)77			X
National Research Council (US)	(1986)78			X
Rice et al.	(1986)79			X
Schelling	(1986)80		X
Stoddart et al.	(1986)81			X
US Dept of Health and Human Services	(1986)82			X
Wright	(1986)83			X
Western Australia Health Dept	(1987)84		X
Maynard et al.	(1987)24		X
Choi and Nethercott	(1988)85@
Gray et al.	(1988)86@
Shimizu et al.	(1988)87		X
Swank et al.	(1988)88		X
Hauswald	(1989)89@
Jackson et al.	(1989)90		X
Kaplan et al.	(1989)91		X
Kristein	(1989)92		X
Manning et al.	(1989)33		X	X
Markandya and Pearce	(1989)93		X
Maynard	(1989)35@
Rivo et al.	(1989)94@
Shoven et al.	(1989)95			X
Wassilak et al.	(1989)96@
Davis et al.	(1990)97@
Gorsky et al.	(1990)98@
Lippiatt	(1990)99		X
Raynauld and Vidal	(1990)100@
Smith et al.	(1990)101		X
Spiegel and Cole	(1990)102@
Ellemann--Jensen	(1991)103@
Shultz et al.	(1991)104@
Chudy et al.	(1992)105@
Cummings et al.	(1992)106@
Hodgson	(1992)107@
Kendall	(1992)108@
Phillips et al.	(1992)109@
Raynauld and Vidal	(1992)110@
Choi	(1993)111@
Williams and Franklin	(1993)112@
Adams	(1994)113@
Bartlett et al.	(1994)114@
CDC	(1994)116@
Li et al.	(1994)117@
Chen et al.	(1995)118@
Easton	(1995)119@
Fox et al.	(1995)52@
Watson et al.	(1995)121@
Welch et al.	(1995)122@
Choi and Pak	(1996)2@
Collins and Lapsley	(1996)136@
Doran et al.	(1996)123@
Emont	(1996)124@
Lynch and Hopkins	(1996)125@
McGhan and Smith	(1996)126@
Schumacher	(1996)127@
Single et al.	(1996)3@
Xie et al.	(1996)58@
Aligne and Stoddard	(1997)128@
Kaiserman	(1997)4@
Stoddard and Gray	(1997)129@
R = Rice et al. (1990)5 C = Collins and Lapsley (1991)1 M = Manning et al. (1991)6 F = French et al. (1991)7

TABLE 1C Previous cost studies of alcohol, tobacco and illicit drugs reviewed by four major recent studies, or identified in literature search@: (C) ILLICIT DRUGS
Author(s)	Year	R	C	M	F
Cruze et al.	(1981)12	X		X	X
Harwood et al.	(1984)16	X		X	X
Adrian et al.	(1989)130@
Fazey and Stevenson	(1990)131@
Thornton et al.	(1990)38@
Cartwright and Kaple	(1991)132@
Rice et al.	(1991)39@
Coordinated Law Enforcement Unit	(1992)133@
Liu	(1992)41@
Clark	(1994)134@
Normand et al.	(1994)49@
Saskatchewan Health	(1994)51@
Fox et al.	(1995)52@
French	(1995)135@
Collins and Lapsley	(1996)136@
French and Martin	(1996)137@
French et al.	(1996)138@
Single et al.	(1996)3@
Xie et al.	(1996)58@
Behnke et al.	(1997)139@
R = Rice et al. (1990)5 C = Collins and Lapsley (1991)1 M = Manning et al. (1991)6 F = French et al. (1991)7

Differences among Previous Studies

Previous cost studies have differed in their point of view, the types of costs included and the basic methodology employed. These differences are briefly outlined below, illustrating the types of decisions that must be made at the outset of a cost study.

A major distinction among cost studies is what viewpoint the study takes. Among the major review articles, the ones by Rice et al.,⁵ Collins and Lapsley¹ and French et al.⁷ took society's point of view; therefore all costs, both internal (costs borne by the substance user and possibly their family) and external (costs borne by those not using the substance), were included. The cost to society resulting from premature mortality, estimated by the value of foregone production, was incorporated in these studies. Transfers within society, such as social welfare payments, were not included because society's total resources did not change as a result of these transfers; the resources were simply redistributed. On the other hand, the costs of administering transfer payments attributable to substance abuse were included because this portion of administrative costs were resources that would not have been consumed in the absence of substance abuse.

In contrast, the review by Manning et al.⁶ considered only the costs that were external to substance users and their families. Thus, in this case, loss of wages due to premature mortality was considered as an internal cost and therefore excluded, whereas transfers from non-users to users via collectively financed programs (such as pension plans and group life insurance) were included.

A third point of view often of interest is that of the government. This is the viewpoint considered in most budgetary impact analyses, such as the one included in the Collins and Lapsley report.¹ Such studies consider revenue from excise taxes, customs duties and income taxes, in addition to costs to health care and justice systems.

Another primary difference among previous studies has been whether costs alone were considered or whether costs and benefits (i.e. net costs) were considered. Cost-of-illness studies—a major type of cost studies—estimate only the costs of substance use.^{5,7,12,16,140-142}  This encompasses direct costs, where payment is made and resources are consumed (e.g. cost of hospital services, motor vehicle damage, justice services), and also indirect costs, where potential resources are foregone through premature mortality or absence from work. Since cost-of-illness studies assess only the costs of substance use, they have been criticized for being of limited usefulness.^143,144 In contrast, the frameworks used by Collins and Lapsley¹ and Manning et al.⁶ considered not only the costs, but also the economic benefits of substance use. For example, premature mortality decreases hospital and nursing home expenditures.

Many studies, such as those of Rice et al.⁵ and Manning et al.,⁶ calculated only tangible costs, i.e. costs that could be valued in the marketplace. However, an economic evaluation is more complete if there is an explicit estimation of intangible costs, such as the cost of pain and suffering.^7,79 Such costs are difficult to evaluate quantitatively, but French et al.⁷ suggested that utility valuation methods could be used, such as the quality-of-life method. Collins and Lapsley¹ actually attempted an explicit calculation of various intangible costs in their review.

A third way in which cost studies can differ fundamentally is in their choice of a "prevalence-based" model^1,5 or an "incidence-based" model.⁶ In the former model, the costs resulting from past and present substance abuse are determined for a given year, based on the prevalence of mortality, morbidity and other relevant factors in that year. For example, Rice et al.⁵ determined costs based on the prevalence of hospitalization, crime, disability, etc. in the year of study that could be attributed to substance abuse. Mortality costs were also based on the prevalence of mortality in the same year, although they were valued as the present value of all future earnings of the deceased (i.e. the "human capital approach").

In another prevalence-based approach, the "demographic approach" (pioneered by Collins and Lapsley¹), a hypothetical population free of substance abuse is constructed for the year of interest (i.e. a larger and healthier population) and the difference in production, health care usage, nursing home care, etc. between the actual and hypothetical populations is estimated. In terms of mortality costs, the human capital approach addresses the question "What does substance abuse today cost the economy this year and into the future?", while the demographic approach asks, "What has substance abuse in the past cost the economy this year?" Thus, the human capital and demographic approaches are complementary, not contradictory.¹⁴⁵ The drawback of prevalence-based models is that, by measuring costs in the present year, they reflect the historical use of a substance. This is illustrated especially in the case of tobacco, which has a long delay between use and consequences. However, because of their simpler data requirement, prevalence-based models have been more widely adopted than incidence-based models.

In contrast to the prevalence-based model, an incidence-based model estimates the present value of the lifetime costs of present substance use patterns. Thus, it can be used to predict the future effect of changes in current substance use patterns and, as such, is generally of greater interest to policy makers.¹⁴⁶ The disadvantages of incidence-based models are that they are very sensitive to as yet unknown technological, demographic, medical and other changes, and that they require sophisticated data.

The terms "private cost" and "social cost" are also used in the literature, although no universally accepted definitions are available. It is generally agreed that private costs, which are the costs the user must pay, are the same as internal costs. Many authors, such as Markandya and Pearce,⁹³ and Collins and Lapsley,¹ define social costs as those that are neither private nor internal. It must be noted, however, that the exact meaning of social costs must be made explicit, since some authors (such as Ellemann-Jensen,¹⁰³ French et al.⁷ and Manning et al.⁶) define social costs as the sum of internal (costs incurred by the individuals engaging in the activity) and external costs (costs to others).

Cost Categories Used in Existing Review Studies

As discussed above, different methods have been used for cost estimation of substance abuse in the four major review studies identified. A comparison of the cost categories considered by these reviews is outlined in Tables 2A, 2B and 2C. These categories are classified as direct costs (expenditures or resources used as a direct result of ATD abuse), indirect costs or intangible costs (generally unquantifiable). The inclusion (indicated with an "X" in the tables) or exclusion of each cost category provides a rough idea of its relative importance within the methodology used by each of the reviews.

Some of these reviews suggested that cost estimations should be classified as core or related costs,^1,5 and internal or external costs.⁶ Collins and Lapsley¹ defined private, social, marginal, real and pecuniary costs, while French et al.⁷ defined private, external and social costs, as well as economic transfers. These are all useful definitions and concepts; however, they are not used in Table 2 in order to simplify the framework.

TABLE 2A Cost categories for abuse of alcohol, tobacco and illicit drugs (ATD) used in four major recent reviews: (A) DIRECT COSTS
Cost categories		R	C	M	F
1.	Hospitalization	X	X	X	X
2.	Physician visits	X	X	X	X
3.	Crime-related costsa	X	X	X	X
4.	Motor vehicle crashesb	X	X	X	X
5.	Nursing home stay	X	X	X
6.	Property and forest firesc	X	X	X
7.	Specialty institutionsd	X	X		X
8.	Professional services (other than physicians)e	X	X		X
9.	Prescription drugs for treatment	X	X		X
10.	Medical and health services research	X	X
11.	Program administrationf	X		X
12.	Administrative costs of private insurance to treat ATD disorders	X		X
13.	Direct costs related to AIDS due to drug abuse (treatment) not already included elsewhere	X			X
14.	Costs of abused substances		X	X
15.	Prevention programsg		X		X
16.	Ambulance costsh		X		X
17.	Training costs for physicians and nurses	X
18.	Fetal alcohol syndromei	X
19.	Customs and immigration		X
20.	Extra neonatal care (neonatal complications caused by mothers' smoking)			X
21.	Neonatal disorders and complications related to drug abuse				X
22.	Home care (care of ATD user)				X
23.	Household help (care of house)				X
24.	Counselling, retraining and re-education				X
25.	Special equipment for rehabilitation (e.g. wheelchairs)				X
26.	Employee assistance programs provided by employers for ATD-using employees				X
27.	Drug testing in workplace				X
28.	Avoidance behaviour costsj				X
29.	Group life insurancek			X
30.	Widow's bonus from husband dying at age 60-79l			X
31.	Extra disability pension due to retirement for health reasonsm			X
32.	Payroll taxes on earnings that finance medical, sick leave, disability, group life insurance and retirement benefitsn			X
33.	Insured cost of care for fetal alcohol syndrome			X
a Includes public criminal justice system cost, corrections, drug traffic control expenses, private expenditure for legal defence, value of property destroyed in crimes due to ATD abuse b Includes legal and court proceedings, insurance administration, accident investigation, vehicle damage, traffic delay c Includes damage and cleaning of damaged goods. Fire injuries and deaths are considered under morbidity and mortality. d Includes treatment centres other than hospitals, and alcohol, tobacco or drug correctional facilities e Includes psychologists, social workers, nurses, physical and occupational therapists, pharmacists, technicians, etc. f ATD-related programs and social welfare programs g Screening, education programs and mass media campaigns to inform the public about the hazards of ATD abuse h Includes other transportation to health care providers i Treatment, rehabilitation and long-term care services for physical and mental deficiencies of children born of mothers who drank during pregnancy j Avoidance behaviour by families, communities and victims of crime, e.g. educational and public service efforts, law enforcement, community-based programs, family-based activities, support services, business and residential security systems, business and residential relocations, insurance, community watch programs k Death benefits provided by employers, usually not adjusted for habits and reduced to zero at retirement l When wife outlives male pensioner and her social security pension increases if she never worked m Non-smokers receive less in disability pension than do smokers since smoking is causally related to disability retirement. n Paid as taxes, premiums, payroll deductions and employer contributions
R = Rice et al.(1990)5 C = Collins and Lapsley (1991)1 M = Manning et al. (1991)6 F = French et al. (1991)7

TABLE 2B Cost categories for abuse of alcohol, tobacco and illicit drugs (ATD) used in four major recent reviews: (B) INDIRECT COSTS
Cost categories		R	C	M	F
1.	Morbidity costs: income loss due to ATD abuseo	X	X	X	X
2.	Related productivity lossesp	X	X	X	X
3.	Mortality costs: present value of lifetime earningsq	X			X
4.	Foregone consumptionr		X
5.	Reduced property values in drug-ridden communities				X
o Value of goods and services lost by individuals unable to perform their usual activities or to perform them at a level of full effectiveness due to disability, absenteeism, etc. p Loss of innocent lives and work time caused by passive smoking and drunk-driving accidents, lost work time for crime victims, productivity loss for individuals incarcerated for a criminal offence and for heroin and cocaine addicts who engage in criminal activities rather than legal employment, time spent to care for family members because of their ATD abuse q Current monetary value of future output lost due to premature death r Reduction in consumption resulting from ATD abuse-induced deaths, which is a net resource benefit to society, considered as a negative cost

TABLE 2C Cost categories for abuse of alcohol, tobacco and illicit drugs (ATD) used in four major recent reviews: (C) INTANGIBLE COSTS
Cost categories		R	C	M	F
1.	Homelessness associated with ATD abuse	X			X
2.	Pain and suffering of victims and the rest of the community		X	X
3.	Value of lost life to the deceased (estimated by willingness to pay to avoid death)		X
4.	Loss of consumption by prematurely deceased		X
5.	ATD abuse-related pain and sufferings				X
6.	Family disruptionst				X
7.	Community disruptionsu				X
s Depression, isolation, heightened anxiety, loss of companionship, loss of job, physical disability, reduced self-esteem, resentment t Parent-child conflicts, spousal conflicts, separation, divorce, marital violence, child abuse u Safety problems, fear for personal safety, fear of property loss, community conflicts

Inventory of Existing Data Sources in Canada

Researchers conducting a cost study are initially faced with the central question of where to find relevant data. Thus, an inventory of possible data sources for cost studies would be extremely valuable. Because of our particular expertise and experience with the Canadian system, we have created an inventory of data sources available in Canada. We considered a similar inventory for various countries to be beyond the scope of this paper because of the size, complexity and differences of such data systems.

Table 3 identifies the Canadian cost studies we used to set up the inventory (Tables 4A, 4B and 4C) of the various data sources in Canada on alcohol, tobacco and drugs. All of these studies evaluated only tangible costs.

TABLE 3 Canadian cost studies used for Table 4
Study	Substance
Forbes and Thompson (1983)	Tobacco65
Collishaw and Myers (1984)	Tobacco70
Choi and Nethercott (1988)	Tobacco85
Adrian (1988)	Alcohol27
Alcohol and Drug Dependency Commission (Nfld) (1988)	Alcohol26
Adrian et al. (1989)	Alcohol30
Adrian et al. (1989)	Drugs130
Kendall (1992)	Tobacco108
Raynauld and Vidal (1992)	Tobacco110
Coordinated Law Enforcement Unit (BC) (1992)	Drugs133
Saskatchewan Health (1994)	Alcohol and Drugs51
Choi and Pak (1996)	Tobacco2
Single et al. (1996)	Alcohol, Tobacco and Drugs3
Kaiserman (1997)	Tobacco4

TABLE 4A Data sources used by Canadian researchers for estimating tangible costs of alcohol, tobacco and drug (ATD) abuse: (A) BACKGROUND INFORMATION
Researchers		Source of data
1. Population structures by age and sex
	Forbes and Thompson (1983)65	Statistics Canada (1979)147
	Kendall (1992)108	Statistics Canada: 1986 Census of Canada
	Single et al. (1996)3	Statistics Canada (1994)148
2. Percentage of population exposed to risk of ATD abuse, by age and sex
	Forbes and Thompson (1983)65	Canada's Labour Force Survey, 1975
	Collishaw and Myers (1984)70	Canada Health Survey
	Choi and Nethercott (1988)85	Canada Health Survey (Statistics Canada, 1983)149 City of Toronto Community Health Survey (MacPherson, 1984)150
	Adrian et al. (1989a)30	Gallup Poll (1984)151
	Kendall (1992)108	Canada's Labour Force Survey (Health and Welfare Canada, 1990)152
	Saskatchewan Health (1994)51	Canada's Health Promotion Survey, 1990
	Choi and Pak (1996)2	Canada's Labour Force Survey (Health and Welfare Canada, 1990)152
	Single et al. (1996)3	Canada's Health Promotion Survey, 1990 Canadian Alcohol and Drug Survey, 1994 Ontario Adult Alcohol and Drug Survey, 1994 Ontario Health Survey, 1990 General Social Survey, 1991 Health Canada Survey on Smoking, Cycle 3, 1994
	Kaiserman (1997)4	General Social Survey, 1991
3. Relative risks of mortality, disability, hospitalization, physician visits, etc., by age and sex
	Forbes and Thompson (1983)65	US Department of Health, Education and Welfare (1979)153
	Collishaw and Myers (1984)70	Hammond (1966)154 Rogot (1974)155
	Choi and Nethercott (1988)85	Collishaw and Myers (1984)70
	Adrian et al. (1989a,b)30,130	Holmes (1976)156
	Kendall (1992)108	US National Health Interview Survey (US Dept of Health and Human Services, 1987)157
	Raynauld and Vidal (1992)110	Reports of the US Surgeon General, 1982, 1983, 1984
	Kaiserman (1997)4	General Social Survey, 1991
	Choi and Pak (1996)2	Collishaw and Myers (1984)70
	Single et al. (1996)3	English et al. (1995)168
4. Mortality rates by age and sex
	Forbes and Thompson (1983)65	Statistics Canada (1980)158
	Kendall (1992)108	City of Toronto Department of Public Health: Information Section
	Single et al. (1996)3	Statistics Canada (1993)115
5. Directly determined attributable fractions
	Single et al. (1996)3	Alter et al. (1989;1990)166,167 Shultz et al. (1991b)40 English et al. (1995)168 Fox et al. (1995)169 Rehm et al. (1996)170

TABLE 4B Data sources used by Canadian researchers for estimating tangible costs of alcohol, tobacco and drug (ATD) abuse: (B) DIRECT COSTS
Researchers		Source of data
1. Hospitalization due to ATD abuse
	Forbes and Thompson (1983)65	Boulet and Grenier (1978)159 Statistics Canada (1978)160
	Collishaw and Myers (1984)70	Canada Health Survey (Statistics Canada, 1983)149
	Choi and Nethercott (1988)85	Ontario Ministry of Health (1984)161 and Information Resources and Services Branch
	Adrian et al. (1989a,b)30,130	Statistics Canada (1988)162-164
	Kendall (1992)108	Ontario Ministry of Health: Financial Services Branch
	Raynauld and Vidal (1992)110	Statistics Canada: Canadian Centre for Health Information
	Kaiserman (1997)4	Statistics Canada
	Choi and Pak (1996)2	Ontario Ministry of Health (1988)165 and Community Information Section
	Single et al. (1996)3	Alter et al. (1989; 1990)166,167 Shultz et al. (1991b)40 English et al. (1995)168 Fox et al. (1995)169 Rehm et al. (1996)170 Statistics Canada (1994)171,120
2. Physician visits
	Forbes and Thompson (1983)65	Boulet and Grenier (1978)159
	Collishaw and Myers (1984)70	Canada Health Survey (Statistics Canada, 1983)149 Régie de l'assurance maladie du Québec (1980)172
	Choi and Nethercott (1988)85	Canada Health Survey (Statistics Canada, 1983)149 City of Toronto Community Health Survey (MacPherson, 1984)150 Ontario Ministry of Health: Information Resources and Services Branch
	Kendall (1992)108	Ontario Ministry of Health: Communications Branch
	Choi and Pak (1996)2	Canada Health Survey (Statistics Canada, 1983)149 Ontario Ministry of Health: User Support Branch
	Single et al. (1996)3	Health Canada (1996)173 Manitoba Health: Health Information System Branch
	Kaiserman (1997)4	Canadian Medical Association
3. Crime-related costs
	Adrian et al. (1989a,b)30,130	Statistics Canada (1988)162-164
	Coordinated Law Enforcement Unit (1992)133	Municipal police agencies Royal Canadian Mounted Police (RCMP) Coordinated Law Enforcement Unit Health and Welfare Canada: Bureau of Dangerous Drugs British Columbia Transit Security British Columbia Ministry of Attorney General: Court Services Branch and Corrections Branch Department of Justice Canada Legal Services Society Correctional Service Canada National Parole Board British Columbia Board of Parole
	Single et al. (1996)3	Statistics Canada (1994)174,175
4. Motor vehicle crashes
	Adrian (1988)27	Ontario Ministry of Transportation and Communications (1985)176 Insurance Bureau of Canada (1982; 1986)177,178
	Coordinated Law Enforcement Unit (1992)133	Royal Canadian Mounted Police (RCMP) CounterAttack Stoduto et al. (1991)179 Insurance Corporation of British Columbia
	Single et al. (1996)3	Blincoe and Faigin (1993)180 Traffic Injury Research Foundation (1992)190 Groupement d' Assureurs automobiles Insurance Bureau of Canada Insurance Corporation of British Columbia Manitoba Public Insurance
5. Nursing home stay
	Kendall (1992)108	Ontario Ministry of Health: Fiscal Resources Branch
6. Property and forest fires
	Collishaw and Myers (1984)70	Dominion Fire Commissioner (1981)181 Ontario Ministry of Natural Resources
	Choi and Nethercott (1988)85	Office of the Fire Marshall (Ontario Ministry of the Solicitor General, 1983)182 City of Toronto Fire Department, 1985 Ontario Ministry of Natural Resources: Aviation and Fire Management Centre, 1985
	Adrian (1988)27	Dominion Fire Commissioner (1981)181
	Raynauld and Vidal (1992)110	Labour Canada (1987)183 Forestry Canada: Petawawa National Forestry Institute, 1989
	Choi and Pak (1996)2	Ontario Ministry of the Solicitor General: Office of the Fire Marshall
	Single et al. (1996)3	Association of Canadian Fire Marshals and Fire Commissioners (1992)184 Statistics Canada (1994)185 Alberta Forest Fire Centre Ontario Ministry of Natural Resources: Fire Statistics Section Nova Scotia Department of Natural Resources: Forest Protection Headquarters Québec Société de protection des forêts contre le feu
	Kaiserman (1997)4	Association of Canadian Fire Marshals and Fire Commissioners (1991)186 Canadian Forest Service
7. Specialty institutions
	Kendall (1992)108	Ontario Ministry of Health: Fiscal Resources Branch
	Single et al. (1996)3	Ellis and Rush (1993)187 Addiction Foundation of Manitoba Statistics Canada (1993; 1994)188,189
	Kaiserman (1997)4	National Population Health Survey, 1994
8. Professional services other than physicians
	Coordinated Law Enforcement Unit (1992)133	British Columbia College of Pharmacists Fan--Out Program
9. Prescription drugs for treatment
	Kendall (1992)108	Ontario Ministry of Health: Drug Programs Branch
	Coordinated Law Enforcement Unit (1992)133	Methadone Maintenance Program
	Single et al. (1996)3	Health Canada: Drugs Directorate
	Kaiserman (1997)4	Health Promotion Survey, 1990 Canadian Pharmaceutical Association
10. Medical and health services research
	Saskatchewan Health (1994)51	Saskatchewan Health Saskatchewan Alcohol and Drug Abuse Commission
	Single et al. (1996)3	Traffic Injury Research Foundation (1992)190 Medical Research Council (1993)191 Alberta Alcoholism and Drug Abuse Commission Alberta Family Life and Substance Abuse Foundation Brewers Association of Canada British Columbia Alcohol and Drug Program National Native Alcohol and Drug Abuse Program Natural Science and Engineering Research Council Ontario Addiction Research Foundation Ontario Tobacco Research Unit
11. Program administration
	Coordinated Law Enforcement Unit (1992)133	Canadian Association of Chiefs of Police: Substance Abuse Program Health and Welfare Canada: Alcohol and Other Drugs Program National Native Alcohol and Drug Abuse Program
	Single et al. (1996)3	Rice et al. (1990)5 Workers' Compensation Board Provincial social services departments
12. Administrative costs of private insurance to treat ATD disorders
	Not considered by Canadian studies reviewed
13. Direct costs related to AIDS due to drug abuse (treatment)
	Coordinated Law Enforcement Unit (1992)133	British Columbia Ministry of Health: Sexually Transmitted Diseases Control Branch, 1989
14. Costs of abused substances
	Not considered by Canadian studies reviewed
15. Prevention programs
	Coordinated Law Enforcement Unit (1992)133	Police Drug Awareness Program The Responsibility Is Yours Program Community Action Program Health Canada's Needle Exchange Program
	Single et al. (1996)3	Canada's Drug Strategy External Affairs Health Canada's Needle Exchange Program National Native Alcohol and Drug Abuse Program Transport Canada Alberta Alcoholism and Drug Abuse Commission Alcoholism Foundation of Manitoba British Columbia Alcohol and Drug Program Ontario Addiction Research Foundation Ontario Ministry of Health: Public Health Branch, Tobacco Strategy Canadian Lung Association
16. Ambulance costs
	Single et al. (1996)3	Canadian Institute for Health   Information
17. Training costs for physicians and nurses
	Saskatchewan Health (1994)51	Saskatchewan Health: Saskatchewan Alcohol and Drug Abuse Commission
	Single et al. (1996)3	Association of Canadian Medical Colleges (1993)192 Statistics Canada (1993)193
18. Fetal alcohol syndrome
	Not considered by Canadian studies reviewed
19. Customs and immigration
	Coordinated Law Enforcement Unit (1992)133	Canada Customs: Intelligence and Interdiction Team Ports Canada Police Waterfront Drug Detection Team
	Single et al. (1996)3	Kiedrowski and Associates (1996)194
20. Extra neonatal care
	Forbes and Thompson (1983)65	Dunn et al. (1976; 1977)195,196 Himmelbeger et al. (1978)197 Rantakallio (1978)198
21. Neonatal disorders and complications related to drug abuse
	Coordinated Law Enforcement Unit (1992)133	Special Care Nursery at British Columbia Children's Hospital Foster care services
22. Home care
	Single et al. (1996)3	Canadian Institute for Health Information
23. Household help
	Not considered by Canadian studies reviewed
24. Counselling, retraining and re-education
	Coordinated Law Enforcement Unit (1992)133	Vocational Rehabilitation of Disabled Persons Program Alcohol and Drug Treatment and Rehabilitation Program
25. Special equipment for rehabilitation
	Not considered by Canadian studies reviewed
26. Employee assistance programs (EAPs)
	Coordinated Law Enforcement Unit (1992)133	Survey of EAPs servicing public and private sector employees
	Single et al. (1996)3	Addiction Management Systems Macdonald and Wells (1994)199
27. Drug testing in workplace
	Not considered by Canadian studies reviewed
28. Avoidance behaviour costs
	Not considered by Canadian studies reviewed
29. Group life insurance
	Alcohol and Drug Dependency Commission (1988)26	Insurance Bureau of Canada
30. Widow's bonus from husband dying at age 60-79
	Not considered by Canadian studies reviewed
31. Extra disability pension due to retirement for health reasons
	Not considered by Canadian studies reviewed
32. Payroll taxes on earnings
	Not considered by Canadian studies reviewed
33. Insured cost of care for fetal alcohol syndrome
	Not considered by Canadian studies reviewed

Discussion

This paper provides a classification scheme for cost categories used by existing methods to estimate the costs of the abuse of alcohol, tobacco and illicit drugs. This scheme was developed through a review of four major recent methodological studies^1,5-7 that themselves were based on review of many other cost studies. We hope that the documentation of a list of these cost studies by substance, year and author(s) will provide researchers with a useful resource for the literature on cost studies.

The classification scheme proposed should facilitate comparative analyses of studies based on different methods. For example, in Canada, most of the mortality and morbidity data required to generate cost estimates is available for each province, but provincial data may not be available in several other areas, such as workplace costs and certain law enforcement costs. Overall cost estimates from different studies are therefore not comparable. By stratifying cost estimates according to our classification scheme, results from different studies can be compared more readily.

The classification framework also allows investigators to customize their own cost studies, using an approach similar to that of French et al.⁷ Cost categories of interest to researchers in a particular study can be identified and selected from the framework to develop a tailor-made model for estimating the costs of ATD abuse in a thorough manner.

This paper also describes a useful inventory of existing data sources in Canada that we hope can be used as a starting point for researchers who would like to conduct their own cost studies, whether in Canada or elsewhere.

Acknowledgments

We thank Rachel Moore from Health Canada for her valuable comments and suggestions.

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Author References

Bernard CK Choi, Bureau of Cardio-Respiratory Diseases and Diabetes, Laboratory Centre for Disease Control, Health Canada, Tunney's Pasture, AL: 0602D, Ottawa, Ontario  K1A 0L2; Fax: (613) 954-8286; E-mail: Bernard_Choi@hc-sc.gc.ca; and Associate Professor, University of Toronto; and Adjunct Professor, University of Ottawa
Lynda Robson, Institute for Work and Health, Toronto, Ontario
Eric Single, Department of Public Health Sciences, University of Toronto, Toronto, Ontario