Smoking's EU hospital bill: EUR 5bn in Spain alone, and the authors call it a floor

Tobacco control in the European Union has an awkward status: broadly agreed on in principle, largely stalled in practice. A study in BMJ Public Health sets out the case in the terms finance ministries respond to, estimating what smoking costs EU hospital systems in two specific categories of care [s1].

The authors' starting position is blunt. Despite significant progress in the past decade, the EU tobacco epidemic remains one of the world's most important; the decline in smoking prevalence has stagnated in recent years, and little legislative progress has been made on tobacco control policies [s1].

What was measured, and what was left out

The analysis uses 2019 data from the European Health Interview Survey, covering all EU Member States except France, Germany, Ireland and Sweden, which were excluded because of data access and data quality reasons [s1]. It applies econometric methods to examine the differential use of inpatient and daycare hospitalisation services among smokers and never smokers, then computes smoking-attributable costs for those services across Member States [s1].

Smoking was positively associated with both inpatient and daycare hospitalisation [s1].

The country range is wide, as it must be given differences in population size, smoking history and unit costs. Smoking-related inpatient hospitalisation costs ranged from EUR 5 billion in Spain to EUR 28 million in Latvia [s1]. For daycare services the range ran from EUR 550 million in the Netherlands to EUR 3 million in Malta and Slovenia [s1].

The exclusion list is as important as the estimate. The authors state that the total healthcare costs of smoking are likely to be significantly higher than reported, because the study covers only two types of healthcare service [s1]. Primary care, outpatient specialist care, prescription medicines, long-term care and the entire productivity side of the ledger sit outside the calculation.

That is a defensible design choice — hospitalisation is what the European Health Interview Survey can measure consistently across countries — but it means the figures should be read as a floor established on comparable data, not as the cost of smoking.

Where a survey-based estimate is weak

Four excluded Member States include the EU's two largest by population, which limits what can be said about an EU-wide total [s1]. The survey is self-reported, so both smoking status and hospitalisation use depend on what respondents say; never-smokers are the comparison group, which avoids some misclassification but not all.

The deeper limitation is that this is an association converted into an attribution. Smokers differ from never smokers in income, occupation, alcohol use and much else, and an econometric adjustment recovers a smoking-attributable share under assumptions that cannot be fully tested inside a cross-sectional survey. The authors present the result as an updated estimate of the healthcare costs of smoking in the EU [s1], which is the appropriate register.

The same question, asked from claims data

A study published seven weeks later ran the equivalent exercise in South Korea using a very different data source, and the contrast is instructive about what each method can deliver.

That analysis linked annual National Health Insurance Service claims for all beneficiaries from 2014 to 2024 with disease-specific population attributable fractions derived from the Global Burden of Disease study, expressing costs in 2024 US dollars [s2]. Smoking-attributable medical spending totalled USD 29.86 billion over the period [s2]. In 2024 alone, costs reached USD 3.38 billion, representing 19.7% of expenditure on the analysed conditions and approximately 4.0% of national health expenditure [s2].

Claims data allow a breakdown a survey cannot support. The fiscal burden was shared between public insurers at 82.5% and households at 17.5% out of pocket [s2]. Costs were highest among men (80.1%) and adults aged 50–79 (80.7%), which the authors attribute to a lagged epidemic driven by historical exposure [s2]. The top 10 conditions accounted for 88.2% of total smoking-attributable spending, with cancers absorbing 35.2% and cardiometabolic diseases 53.1% [s2].

The most striking figure concerns second-hand smoke. Costs for men were driven by active smoking at approximately 90%, while costs for women were largely attributable to second-hand smoke, which accounted for 48% of their total costs against 9% for men [s2]. Overall, second-hand smoke accounted for 16.5% of costs [s2].

Neither number is transferable to Europe — the exposure histories, insurance architecture and price levels differ — but the methodological point carries. A national claims system linked to attributable fractions produces a payer breakdown and a sex-specific exposure split; a cross-national health interview survey produces comparability across most of the EU at the cost of covering only two service types.

What this does and does not tell policymakers

The Korean authors draw an explicit policy inference: that the current decline in smoking prevalence is insufficient to arrest the rising financial momentum of historical exposure, and that a polluter-pays framework correcting tobacco prices to include social costs would recover public health expenditure [s2]. The EU authors stop earlier, concluding that the updated estimates underscore the need to reinvigorate tobacco control policies at national and EU level to reduce the health and economic burden of smoking and protect health system resources [s1].

Both are advocacy conclusions drawn from descriptive cost estimates, and neither study evaluates a policy. Nothing in either paper establishes what a given tax increase, advertising restriction or smoke-free extension would save; that requires intervention evidence these designs do not provide.

What they do supply is the denominator for that argument. Any debate about the cost of tobacco control now has an EU-comparable hospitalisation figure that its own authors describe as an undercount [s1], and a decade-long claims series from a high-income Asian system showing roughly 4% of national health spending traceable to smoking in a single year [s2].

Sources

• Smoking-attributable hospitalisation costs in Europe: an econometric analysis of the European Health Interview Survey, 2019, BMJ Public Health, 3 March 2026
• The toll of tobacco: smoking-attributable health spending in South Korea, 2014–2024. National claims evidence for cost recovery, The Lancet Regional Health – Western Pacific, published online 28 April 2026