title: Economic burden of smoking: a systematic review of direct and indirect costs.
abstract: BACKGROUND
  Smoking imposes considerably high economic costs both on the healthcare system as well as on a country as a whole. This study was aimed at systematically reviewing the currently published literature on the direct and indirect costs associated with smoking globally.
  
  
  METHODS
  A systematic review was performed on systematically searched articles from PubMed and Scopus databases published during the period 1990 to 2014. A combination of key terms such as "economic burden", "direct cost", "indirect cost", and smoking, tobacco or cigarette" and "productivity lost was used for the search. Original research article published in English with the age of study population greater than 35 years, at least three smoking-related diseases and reported direct or indirect cost of smoking were the inclusion criteria.
  
  
  RESULTS
  Fourteen original articles were included in the review. The cost of outpatient care and premature deaths were found to be the most important cost driver of direct and indirect costs respectively. The study showed that smoking-related diseases were responsible for 1.5 - 6.8 % of the national health system expenditures and 0.22-0.88% of GDP of a country.
  
  
  CONCLUSIONS
  Our review indicated that the costs of smoking are substantial, and smoking have a significant impact on the economy of a country. Policies such as increasing the taxation on a cigarette are required and should be implemented to reduce the economic burden of smoking.
authors: PhD Candidate in Health Economics, Research Center for Environmental Determinants of Health, Kermanshah University of Medical Sciences, Kermanshah, Iran. satarrezaei@gmail.com.
authors: Satar
authors: S
authors: Rezaei
authors: PhD, Associate Professor, Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran. akbarisari@tums.ac.ir.
authors: Ali
authors: A
authors: Akbari Sari
authors: Professor, Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran. arabmoha@tums.ac.ir.
authors: Mohammad
authors: M
authors: Arab
authors: Professor, Department of Epidemiology and Biostatistics, School of Public Health and Knowledge Utilization Research Center, Tehran University of Medicalُ Sciences, Tehran, Iran. rezamajd@tums.ac.ir.
authors: Reza
authors: R
authors: Majdzadeh
authors: Assistant Professor, Department of Statistics and Epidemiology, Tabriz Health Services Management Research Center, Tabriz University of Medical Sciences, Tabriz, Iran. poorasl@yahoo.com.
authors: Asghar
authors: A
authors: Mohammad Poorasl
keywords: Direct costs; Indirect costs; Smoking; Systematic review