International Journal of Drug Policy 44 (2017) 50–57
Contents lists available at ScienceDirect
International Journal of Drug Policy
journal homepage: www.elsevier.com/locate/drugpo
Research paper
Economic consequences of legal and illegal drugs: The case of social
costs in Belgium
Delfine Lievensa,b , Freya Vander Laenena,b,* , Nick Verhaeghed, Koen Putmanc ,
Lieven Pauwelsa,b , Wim Hardynsa,b , Lieven Annemansd
a
Ghent University, Institute for International Research on Criminal Policy, Belgium
Ghent University, Department of Criminology, Penal Law and Social Law, Universiteitstraat 4, 9000 Ghent, Belgium
Vrije Universiteit Brussel, Department of Medical Sociology, Belgium
d
Ghent University, Department of Public Health, Belgium
b
c
A R T I C L E I N F O
A B S T R A C T
Article history:
Received 12 July 2016
Received in revised form 31 January 2017
Accepted 20 March 2017
Available online xxx
Background: Legal and illegal drugs impose a considerable burden to the individual and to society. The
misuse of addictive substances results in healthcare and law enforcement costs, loss of productivity and
reduced quality of life.
Methods: A social cost study was conducted to estimate the substance-attributable costs of alcohol,
tobacco, illegal drugs and psychoactive medication to Belgian society in 2012. The cost-of-illness
framework with prevalence-based and human capital approach was applied. Three cost components
were considered: direct, indirect and intangible costs related to substance misuse.
Results: The direct and indirect cost of addictive substances was estimated at 4.6 billion euros in Belgium
(419 euros per capita or 1.19% of the GDP) and more than 515,000 healthy years are lost due to substance
misuse. The Belgian social cost study reaffirms that alcohol and tobacco impose the highest cost to society
compared to illegal drugs. Health problems are the main driver of the social cost of legal drugs. Law
enforcement expenditure exceed the healthcare costs but only in the case of illegal drugs.
Conclusion: Estimating social costs of addictive substances is complex because it is difficult to determine
to what extent the societal harm is caused by substances. It can be argued that social cost studies take
only a ‘snapshot’ of the monetary consequences of substance misuse. Nevertheless, the current study
offers the most comprehensive analysis thus far of the social costs of substance misuse in Belgium.
© 2017 Elsevier B.V. All rights reserved.
Keywords:
Drug policy
Social cost
Illegal drugs
Legal drugs
Health care
Law enforcement
Introduction
Addictive substances are problem worldwide, contributing to
the global burden of disease (Ezzati, Lopez, Rodgers, & Murray,
2004; Rehm, Taylor, & Room, 2006). The use and misuse of tobacco,
alcohol, illicit drugs and psychoactive medication is associated
with an increased risk of developing a number of diseases and
injuries (Fischer, Bibby, & Bouchard, 2010; Rehm et al., 2006, 2003).
Tobacco smoking, including second-hand smoking, accounted for
6.3 million deaths and 6.3% of disability-adjusted life years (DALYs)
worldwide (Lim et al., 2013). Alcohol is responsible for 2.7 million
deaths and 4.6% of all DALYs (Rehm et al., 2009). Illicit drugs
accounted for 158,000 deaths and 0.8% of all DALYs (Degenhardt
et al., 2013). This burden of disease due to addictive substances
* Corresponding author at: Ghent University, Department of Criminology, Penal
Law and Social Law, Universiteitstraat 4, 9000 Ghent, Belgium.
E-mail address: [email protected] (F. Vander Laenen).
http://dx.doi.org/10.1016/j.drugpo.2017.03.005
0955-3959/© 2017 Elsevier B.V. All rights reserved.
results in considerable healthcare costs, loss of productivity
resulting from disability and premature mortality and reduced
health-related quality of life (Rehm et al., 2006).
The impact of legal and illegal drugs is not restricted to public
health. These substances also contribute to the financial and social
burden of crime. Studies have consistently shown a strong relation
between substance misuse and crime (Caulkins & Kleiman, 2011;
Ellis, Beaver, & Wright, 2009). At the neighbourhood level, crimes
rates and rates of substance use and social nuisance are strongly
correlated (Boardman, Finch, Ellison, Williams, & Jackson, 2001),
and at the individual level, drug use has been shown to play a role
in pathways to serious offending (Le Blanc, 2006; Piquero,
Farrington, & Blumstein, 2007); serious offenders are responsible
for a substantial part of crime. The most obvious and straightforward connection can be found in the form of drug law violations
such as trafficking and dealing (EMCDDA, 2007). A more complex
relationship can be found between illicit drug and alcohol use and
non-consensual crimes as the link between both is not defined by
law but by the effect on behaviour (Caulkins & Kleiman, 2014;
D. Lievens et al. / International Journal of Drug Policy 44 (2017) 50–57
51
Table 1
Overview of crime and health cost items included.
Health cost items
Direct costs
& Inpatient care: hospitalization (general and psychiatric hospital admissions),
sheltered housing, psychiatric nursing homes, inpatient rehabilitation
& Outpatient care: physician contacts (GPs, psychiatrists and medical specialists),
day centers, medical-social care centers, mental health care centers and homebased nursing care
& Social work services: general welfare centres, telephone and online support
& Pharmaceuticals
& Prevention (initiatives aimed at health promotion, road safety Institute),
research and coordination (a.o. Belgian monitoring centre for drugs and drug
addiction)
Crime cost items
& Investigation: federal and local police, customs and agencies (a.o. inspection of
alcohol and tobacco retailers, agency tackling money laundering, inspections of
non-smoking facilities)
& Prosecution: public prosecutor’s office and diversion measures
& Sentencing: general courts, legal aid, drug treatment court
& Sentence execution: correctional facilities, community youth institutions,
offender guidance, electronic monitoring, sentencing court, and alternative
sanctions and measures
& Prevention (prevention plans), coordination (Criminal Policy, UNODC) and
research
& Property loss due to theft
& Tax refunds for burglary prevention
& Anticipation to theft
Indirect costs
& Disability: short-term disability (365 days) and long-term disability
(>365 days)
& Productivity losses due to premature mortality
& Productivity losses due to premature mortality (deaths by homicide) and
incarceration
Intangible costs
& Disability-adjusted life years (DALY’s) due to diseases, injuries and traffic
accidents
& Disability-adjusted life years (DALY’s) due to interpersonal violence
Pacula et al., 2013). All these crime types have an impact on the
costs to the criminal justice system, lead to losses to productivity
(due to incarceration) and have an impact on quality of life. The
total cost of drug-related crime is considered to be enormous
(Caulkins & Kleiman, 2011).
The health and crime costs attributable to legal and illegal drugs
have been estimated nationally by multiple social cost studies.
Most of these studies indicated that legal drugs impose the
greatest cost to society because of the high healthcare costs for
alcohol and tobacco related diseases (e.g. Collins & Lapsley, 2008;
Fenoglio, Parel, & Kopp, 2003; Kopp, 2015; Rehm et al., 2007;
Single, Robson, Xie, & Rehm, 1998). These studies also examined
the composition of the social costs by comparing the healthcare
costs with law enforcement and prevention costs. Looking at the
social costs of illegal drugs specifically, most studies reported that
law enforcement expenditure exceeds healthcare costs (Fenoglio
et al., 2003; Potapchik & Popovich, 2014; Rehm et al., 2007).
This article presents an estimate of the total cost of addictive
substances in Belgium for the year 2012 (Lievens et al., 2016). It is
the first study to measure the social cost of four different
substances: alcohol, illegal drugs, tobacco and psychoactive
medication. The misuse of psychoactive pharmaceuticals such as
antidepressants, sedatives, anxiolytics, and antipsychotics are
included. Increasingly these substances are considered to be a
public health concern since a high prevalence of non-medical
prescription drug use has been reported in countries such as the
United States, Canada, Australia, and some European countries
(United Nations Office on Drugs and Crime, 2011). The inclusion of
multiple types of psychoactive medication (antidepressants,
analgesics, anxiolytics, sedatives, hypnotics) is unique (Johnson,
Barnsdale, & McAuley, 2016), as previous studies have limited their
scope to nonmedical use of prescription opioids (Hansen, Oster,
Edelsberg, Woody, & Sullivan, 2011) or the misuse of prescription
opioid analgesics (Birnbaum et al., 2006).
Moreover, the current study estimates tangible and intangible
losses caused by substance misuse. The intangible losses (i.e. the
impact on quality of life) are the costs that society and individuals
are willing to pay to avoid such losses. These costs have not been
studied in previous social cost estimations (except in Collins &
Lapsley, 2008) as it was thought to be extremely difficult to
estimate their monetary value because they have no market price
(Single et al., 2003).1 Furthermore, a wide variety of tangible costs
(i.e. direct costs and productivity losses) are included. These
include costs of an array of substance-attributable diseases and
conditions, (traffic) accidents and crimes (more detail on included
costs is provided in the methods section).
Methods
A cost-of-illness study (COI) was conducted to estimate the
substance-attributable costs of addictive substances to Belgian
society (Bloom, Bruno, Maman, & Jayadevappa, 2001). A wide
variety of costs are taken into account, including private costs (e.g.
payment that a smoker contributes to medical care). These costs
are estimated by comparing the status quo to a hypothetical setting
of no substance use that causes any harm.2 Three cost components
were considered: (1) direct costs, (2) indirect cost, and (3)
intangible costs related to substance (mis)use. Direct costs are
those related to the resources used for dealing with substance use
and related medical conditions, accidents or their proximate
effects (e.g. hospitalisation, physician consultations, medication
use) and substance attributable crime and its consequences
(e.g. police investigation, incarceration). Indirect costs are productivity losses due to disability because of premature mortality
(as a consequence of a disease, accident or crime) or incarceration.
Intangible costs are non-financial welfare costs borne by individuals, such as the value of lost (quality of) life (Moore & Caulkins,
1
In Jarl et al. (2008), quality of life of alcohol consumers, their family and friends
was evaluated by calculating quality-adjusted life years (QALYs), however no
monetary valuation of these QALYs have been reported in this study.
2
For psychoactive medication, a counterfactual with no harm resulting from
pharmaceuticals is also preferred. Consequently, the costs are included for a
hospitalisation due to overconsumption or a traffic accident due to psychoactive
medication use. However, this conceptual framework does not allow an estimation
of the cost of medical use (e.g. purchase of psychoactive medication at the
pharmacy) or the cost of inadequate use (e.g. prescription for one dose
antidepressants).
52
D. Lievens et al. / International Journal of Drug Policy 44 (2017) 50–57
2006; Single et al., 2001). Table 1 provides an overview of the
different cost items included in this social cost study.
The calculation of the direct costs is prevalence-based,
measuring the consequences of substance misuse in a given time
period (in this case the year 2012). The latter is a function of past
and current substance misuse (Moore & Caulkins, 2006).
Productivity losses were estimated using the human capital
approach to measuring current and future productivity losses
which can be attributed to the year of investigation. The lost
productivity from premature mortality was calculated on the basis
of the potential productive life years lost and the annual mean
labour cost for the year 2012. For each ICD-10 diagnosis, the
potential productive life years lost was calculated by subtracting
age at death from retirement age (65 years) and this was multiplied
with the number of deaths at the given age. In order to estimate the
productivity losses due to disability, a sex-specific weighted
average disability benefit/day was calculated accounting for the
sex- and statute (worker/clerk)-specific total number of disability
days and the disability expenditures for 2012 in Belgium. Lost
productivity due to incarceration was calculated by taking into
account multiple indicators: number of incarcerations, average
duration of detention, the percentage of economical active inmates
prior to detention and the daily labour cost.
Intangible costs were calculated using the concept of disabilityadjusted life years (DALYs). DALYs are a measure to quantify
disease burden by taking into account losses of healthy life years
through living with a disease (years lived with a disease—YLD) and/
or through dying before a reference life expectancy (years of life
lost—YLL) (Drummond, Sculpher, Torrance, O'Brien, & Stoddart,
2005). Data on age- and sex-specific DALYs for Belgium were
derived from the World Health Organization (WHO) global burden
of disease DALY estimates for the year 2012. This database contains
sex- and age band (0–4, 5–14, 15–29, 30–59, 60–69, 70 years)specific DALYs for a number of diseases and conditions.
The epidemiological concept of substance-attributable fractions (SAF) (Kleinbaum, Kupper, & Morgenstern, 1982) was used to
quantify the proportion of the total morbidity and mortality of
diseases and conditions that are known to be causally related to
substance (mis)use. SAFs can be calculated using the following
formula:
SAF ¼
Pi ðRRi 1Þ
SPi ðRRi 1Þ þ 1
where Pi signifies the prevalence of substance consumption in
consumption class i (e.g. for tobacco: i = 0, never smokers; i = 1,
former smokers; i = 2, current smokers) and RRi signifies the
relative risk of disease in consumption class i. The prevalence data
were derived from the ‘Belgian Health Interview Survey 2013’
(Tafforeau et al., 2015).3 For alcohol, four sex-specific consumption
classes were considered: (i) abstainers; (ii) class I: drinking 0–
19.99 g/day (females), 0–39.99 g/day (males); (iii) class II: drinking
20–39.99 g/day (females), 40–59.99 g/day (males); and (iv) class
III: drinking 40 g/day (females), 60 g/day (males).4 For tobacco,
three categories were considered: (i) current; (ii) former; and (iii)
never smokers. For illicit drugs and psychoactive pharmaceuticals,
3
The Belgian Health Interview Survey is organised every 4–5 years and collects
health information from around 10,000 individuals in a face-to-face setting. The
National Population Register is used as a sampling frame and a clustered sampling
method is applied.
4
In the Health Interview Survey, drinking categories II and III were considered as
one category ‘Hazardous drinking, females >20 g/day and males >40 g/day’. WHOdata related to the ‘estimated proportion of population of consumption categories II
and III for Eur-A region (including Belgium)’ (Rehm et al., 2004) were used to allow
for an estimation of the proportion of population in the drinking categories II and III
for the SOCOST-study.
two consumption classes were considered: (i) users; and (ii) nonusers. In the ‘Health Interview Survey’, illicit drugs considered
were cannabis, cocaine, amphetamine/ecstasy, heroin or substitutes, and other drugs. Psychoactive pharmaceuticals included
antidepressants, analgesics, and anxiolytics, sedatives and hypnotics.5
Furthermore, the relative risk data of the diseases associated
with substance (mis)use was available for alcohol (Rehm et al.,
2007, 2003; Single et al., 2001), tobacco (Rehm et al., 2006; US
Department of Health and Human Services, 2014), and illicit drugs
(Han, Gfroerer, & Colliver, 2010; MacArthur et al., 2012; Ridolfo &
Stevenson, 2001). For example, the relative risks of diseases
associated with illicit drug use were found for tuberculosis (RR,
2.23) (Han et al., 2010) and HIV disease (RR, 1.54) (MacArthur et al.,
2012). For psychoactive pharmaceuticals’ misuse, no relative risks
needed to be searched for, since all diseases and conditions were
found to be fully attributable to the substance misuse.
These substance-attributable fractions are, for example, used to
estimate (direct) costs for inpatient and surgical hospital day care
episodes. The hospital costs were calculated by multiplying the
age- and sex-specific SAFs, the number of age- and sex-specific
number of hospital care episodes and the weighted average
disease-specific unit costs:
Attributable cost = SAFage- & sex-specific * hospital care episodesage- & sexspecific * weighted mean costage- & sex-specific
We illustrate this for the calculation of the inpatient tobaccoattributable trachea, bronchus, and lung cancer cost in females
aged 65–74 years. The SAF for trachea, bronchus, and lung cancer in
females aged 65–74 years was 0.80. The number of hospital care
episodes in this population was 994, while the unit cost/care
episode was 7376 euros. Applying the above described formula
gives a cost of 5.9 million euros.
The concept of substance-attributable fractions was also
applied to calculate crime costs. These fractions are used to
determine the proportion of non-consensual crimes (property
crimes, violent crimes and sexual crimes) that can be attributed to
substance misuse (Caulkins & Kleiman, 2014; Pacula et al., 2013).
The illicit drug-attributable fractions for crimes registered by the
Belgian integrated police were retrieved from a study on
measuring drug related crime6 (De Ruyver et al., 2008). According
to this study, 7.3% of all property crimes, 1.4% of all violent crimes,
and 19.9% of all sexual crimes could be attributed to illicit drug use.
Because these numbers are police specific, they had to be adjusted
for other levels of the criminal justice system. For the alcoholattributable fractions, there were no reliable Belgian data, thus data
from the German central police agency or Bundeskriminalamt
were used.7 The Bundeskriminalamt reports that 13.4% of all
suspects were under the influence of alcohol at the time of offence
in 2012. No tobacco and psychoactive medication-attributable
fractions were used. Although the literature does discuss a possible
connection between psychoactive medication misuse and some
5
It is not clear if this consists of ‘use’ or ‘misuse’ because no distinction could be
made between respondents using the prescription dose or consuming higher doses
than prescribed.
6
Including psychopharmacological crimes (crimes committed under the
influence of illegal drugs), economic-compulsive crimes (crimes committed to
finance and support illegal drug misuse), systemic crimes (crimes as a consequence
of the illegal character of the drug market and organised crime) and consensual
crimes (drug law offences) (De Ruyver et al., 2008).
7
The data of the German central police agency or Bundeskriminalamt were used
because (1) the prevalence of alcohol dependency is similar in Germany and
Belgium and (2) the German police system shows some parallels with the Belgian
system, although important differences can also be noted. The data are limited to
the number of suspects under the influence at the time of the offence as reported by
the German police, and do not include systemic or economic-compulsive crimes.
D. Lievens et al. / International Journal of Drug Policy 44 (2017) 50–57
forms of crime, such as violent crimes (Haggård-Grann et al. 2006;
Moore, Glenmullen, & Furberg, 2010; Tiihonen et al., 2015), this
effect could be expected to be very small (Moore et al., 2010).
Furthermore, we assume that tobacco does not lead to property,
violent, or sexual crime (Caulkins & Kleiman, 2011). Of course,
tobacco and psychoactive medication law violations, such as
smuggling, forgery, illicit usage, etc. are included.
Furthermore, the costs of traffic accidents caused by substance
misuse were also calculated by applying substance-attributable
fractions. These fractions were based on the prevalence rates of
two DRUID studies8 (Houwing et al., 2011; Isalberti, Van der
Linden, Legrand, Verstraete, & Bernhoft, 2011), these report the
prevalence of alcohol and other psychoactive substances in drivers
who have been injured in traffic accidents and by drivers in general
traffic.
Methodological limitations of the study
This social study can be considered as a comprehensive analysis
of the costs associated with substance misuse, since a wide variety
of cost items, diseases, conditions and crimes (e.g. violent, sexual
and property crimes) was included. Still, the cost estimates here
are an underestimation as some types of social costs are not
included due to missing data: for example, lost productivity
through absenteeism and lost household work (as measured by
Fenoglio et al., 2003; Miller, Levy, Cohen, & Cox, 2006). It should
also be emphasized that the outcome of a social cost study is
strongly determined by methodological choices. For instance, the
assumption is made that the police invests similar amounts of time
and resources in each offence. In other words, we assume that all
criminal activity has the same unit cost. However, a number of
studies (e.g. Aos, 2006; Carey, Crumpton, Finigan, & Waller, 2005)
found that the cost per arrest varies widely. For example, in
Washington State, the average cost of an arrest varies from 31,648
dollars for murder to 5370 dollars for drug offenses (Aos, 2006).
Consequently, the amount of drug expenditures could be
exaggerated.
Moreover, this social cost estimation is restricted by the
available data. This type of study requires extensive data collection
from multiple sources. However, data were mainly retrieved from
existing registration systems which are often incomplete and/or
created for administrative purposes, rather than purposes of
scientific inquiry. In the current study, for example, the last year
prevalence rates of illegal drugs were used, because data on last
month prevalence were only available for cannabis. This may have
resulted in an overestimation of illicit drug prevalence rates since
these data include both occasional and frequent or heavy users.
Consequently, the calculations of health and crime costs were
affected by flawed or inconvenient data. It is also important to
remember that COI methods were developed to estimate the
economic impact of disease, meaning that this methodology is not
designed to measure costs of crime (Kleiman, Caulkins, & Gehred,
2014). For example, no methodological standard is available to
estimate the SAFs for crime (Single et al., 2003), as is the case for
the cost calculation of healthcare. This study has dealt with these
methodological issues by striving for a realistic picture of the social
cost. Nevertheless, the results of a social cost study should be
considered as estimations and interpreted with care.9
8
Driving under the influence of drugs, alcohol and medicines, a study including
more than 20 European countries.
9
The average costs are presented in this paper. The minimum and maximum of
certain costs could be retrieved in the report of the study, including the sensitivity
analyses and scenario analyses (see Lievens et al., 2016).
53
Findings
In 2012, the direct and indirect cost of addictive substances
(illegal drugs, alcohol, tobacco and psychoactive medication) is
estimated at 4.6 billion euros in Belgium or 419 euros per capita or
1.19% of the GDP. About 81% (2.3 billion euros) of the direct costs
are public expenditures and 9% (271 million euros) are private
costs (e.g. out-of-pocket hospital costs, private sponsoring of
prevention).10 Treatment accounts for 75% of the total public direct
costs, and enforcement expenditures represent about one-fourth
(24%). Prevention (0.5%), harm reduction (0.1%) and other activities
such as coordination and research (0.24%) are only minor
components of the direct cost category.
Table 2 demonstrates that legal substances impose the highest
cost to society since 45% (2.1 billion euros) of the social cost on
substance misuse can be attributed to alcohol. About 32%
(1.5 billion euros) can be assigned to tobacco and 5% (215 million
euros) to psychoactive medication. Illegal drugs comprise about
16% (725 million euros) of the economic burden. Furthermore, the
majority of the social costs are related to health problems. In fact,
70% (2.1 billion euros) of the direct costs is used for health care and
95% (1.7 billion euros) of the indirect costs is caused by
productivity losses due to disability and premature mortality.
Crime accounted for 30% (850 million euros, an average of the
minimum and maximum estimation)11 of the substance-attributable direct costs and only 5% (83 million euros) of the indirect
costs.
Health costs
Within the direct health cost category, inpatient care was
responsible for the majority of the substance-attributable costs
(1.55 billion euros, 77.2%), followed by outpatient care with 21.3%
(428.3 million euros). Minor costs items are pharmaceuticals
(0.54%), prevention (0.45%), coordination and research (0.26%)
and social work services (0.24%). The hospital care episodes
(excluding traffic injuries) in general hospitals and in psychiatric
hospitals accounted for 52.5% (770 million euros) and 47.5%
(670 million euros) respectively. This accounted for 128,689 care
episodes in general hospitals and 42,359 care episodes in
psychiatric hospitals that could be attributed to substance misuse.
Within the category of indirect health costs, 1.3 billion euros (76%
of the indirect health costs) are productivity losses from premature
mortality due to diseases and conditions associated with substance
misuse.
Crime costs
The direct crime costs are mainly attributable to illegal drugs
(54%) and to alcohol (42%). The largest share of direct costs is
situated at the investigation level (30.5% or 258 million euros) and
at the sentence execution level (28% or 237 million euros). Some
minor costs could be found for the sentencing level (5.03%), for the
10
The remaining 10%, 284 million euros for “anticipation to theft’, “property loss
because of theft” and “tax refunds burglary prevention“, are reported separately
since they could be considered as transfer costs.
11
The costs for the penitentiary institutions are based on the annual number of
incarcerations and the population on a given date (March 1, 2012). However, it is
possible to be incarcerated for multiple offences at the same time. In order to avoid
overlap when calculating the costs, we use a minimum and maximum estimation of
the total expenditure. The minimum calculation only takes incarcerations into
account for a single offence (e.g., only a violent crime) and the maximum calculation
takes incarcerations into account for multiple offences (e.g., a violent crime and a
property crime). A similar calculation was used for the costs related to the
sentencing courts.
54
D. Lievens et al. / International Journal of Drug Policy 44 (2017) 50–57
Table 2
Overview of the direct and indirect costs (million euros), 2012.
Direct cost
Health
Crime
Indirect cost
Health
Crime
Total
Alcohol
Tobacco
Illegal drugs
Psychoactive medication
Other/combinations
Total
927
363
1290
713
14
727
147
459
606
112
14
125
113
0.8
114
2013 (70.3%)
850 (29.7%)
2863
739
39
746
76
43
90
0.2
30
778
746
120
90
30
1681 (95%)
83
(5%)
1764
2068
44.7%
1473
31.9%
725
15.7%
215
4.6%
144
3.1%
4627
100%
Table 3
Overview of the intangible costs (years), 2012.
Alcohol
Tobacco
Illegal drugs
Psychoactive medication
Other/combinations
Total
Health
Crime
171,710
3619
295,406
3430
796
3850
36,311
510,707 (99.1%)
4415
(0.9%)
Total
175,329
34%
295,406
57.3%
4226
0.8%
3850
0.7%
36,311
7%
515,122
100%
prosecution level (2.50%), for prevention (0.42%) and for research/
coordination (0.01%).12
Concerning the indirect crime costs, 60% (49 million euros) can
be attributed to productivity losses due to incarceration (an
average of the minimum and maximum estimation) and 40%
(33 million euros) can be attributed to productivity losses because
of premature mortality by homicide.
Table 3 illustrates that, next to the direct and indirect costs,
more than 515,000 healthy years are lost due to substance (mis)
use. Belgium was confronted with a total loss of 3,259,200 DALYs
(all causes) in the year 2012. Consequently 16% of the DALYs are
caused by substances. Again, this is mainly tobacco and alcohol
(mis)use; both substances are responsible for approximately 91%
or 470,735 healthy years lost. And again, these intangibles are
mainly caused by health problems13 . Taking into account an
economic cost of 40,000 euros per DALY (an amount used by the
European Commission, Desaigues et al., 2007), we obtain a societal
loss of 20.6 billion euros.
Discussion
Social cost studies could be used as an economic tool to evaluate
drug policy, since these studies indicate which substances are most
harmful for society. From this point of view, a social cost analysis
provides information for decision makers to monitor the resource
allocation in accordance with the economic burden of different
health problems (Bhattacharya, 2016; Ritter, Chalmers, & Berends,
2015). Moreover, the economic impact of policy choices can be
12
The remaining 33.52%, 284 million euros for “anticipation to theft’, “property
loss because of theft” and “tax refunds burglary prevention”, are transfer costs
(Czabanski, 2008; McCollister, French, & Fang, 2010).
13
Still, it is highly likely that the intangible costs of crime are underestimated,
since there are only data available on the number of DALYs lost due to interpersonal
violence. There are no data available on other types of crime, such as sexual crimes
or property crimes.
diverted from a social cost study (Vander Laenen and Lievens, in
press). In fact, these studies provide insight into how government
budgets are composed or what the public authorities’ ‘policy mix’
is. By doing so, the prevailing balance between the various sectors
of drug policy (prevention, treatment, harm reduction and law
enforcement) becomes visible (EMCDDA, 2014; Moore, 2008;
Vander Laenen, Vandam, De Ruyver, & Lievens, 2008).
Social cost studies have distinguished a general pattern of high
social costs on legal drugs, however these findings contrast with
the policy and political focus on illegal drugs in most countries
(McDonald, 2011). As already stated in 1995 (by Reuter and
Caulkins, 1995, p. 1061): “including alcohol and cigarettes would
allow integrated policy and ensure that all drugs are given proper
emphasis in the key decisions about health care and crime control.”
The idea of illegal drugs as dangerous and evil has led to a war on
drugs and zero-tolerance policies. The prohibition and criminalisation of illegal drugs results in enforcement-heavy policies,
however this policy approach has detrimental effects on public
health. For example, the excessive use of incarceration as drugcontrol measure has led to increased HIV and hepatitis infections
due to drug use in prisons (Csete et al., 2016; Fazel & Baillargeon,
2011). The Lancet Commission on Drug Policy and Health invokes
health, human rights and development arguments to reform drug
policy (Csete et al., 2016), however no economic arguments have
been put forward in the debate.
This Belgian social cost study researched the costs of multiple
addictive substances (alcohol, tobacco, illegal drugs and psychoactive medication).14 It reaffirmed that alcohol and tobacco impose
the highest cost to society in comparison to illegal drugs. Alcohol,
tobacco and psychoactive medication are responsible for 74.8% of
14
Future social cost studies should include the costs related to new psychoactive
substances (NPSs) as well, in view of an increasing number of NPS seizures by law
enforcement and a growing number of serious harms to users due to NPS over the
past few years in Europe (EMCDDA, 2015).
D. Lievens et al. / International Journal of Drug Policy 44 (2017) 50–57
the direct costs and 91.5% of the indirect costs. This study has also
shown that health problems are the main driver of the social cost of
legal drugs. Half of the hospitalisation costs (general and
psychiatric) were associated with alcohol (mis)use, followed by
tobacco (34%) (whereas the impact of psychoactive pharmaceuticals on hospitalisation is limited to 5% of substance related
hospital costs). As could be expected, for illegal drugs, our study
reaffirmed that crime related costs exceed the healthcare costs
(Collins & Lapsley, 2008; Fenoglio et al., 2003; Potapchik &
Popovich, 2014; Rehm et al., 2007; Single et al., 1998).
Important differences with existing social cost studies were
also found. A Russian study reported that the cost of illegal drugs
(30%) is higher than the cost of tobacco (25%), contradicting the
findings in all other social cost studies executed so far. The
enforcement policy in Russia had a considerable impact on the
social costs for illegal drugs, more than 89% of the direct costs of
illegal drugs are used for law enforcement and criminal justice, and
only 11% are medical costs (Potapchik & Popovich, 2014). A French
study, indicated that the social costs of illegal drugs are mainly
used for healthcare (62% of the public cost in comparison to 38% for
law enforcement and prevention) (Kopp, 2015). These examples
clearly illustrate that social costs are determined by multiple
factors such as drug policy, healthcare policy, prevalence and the
socio-economic context and therefore sufficient context should be
added to interpret the results of social cost studies (Vander Laenen
and Lievens, in press).
Notwithstanding the merits of social costs studies in the drug
policy debate, these are confronted with limitations. Estimating
social costs of substances is complex because it is difficult to
determine to what extent the societal harm is caused by the
substance. One could state that social cost studies take a ‘snapshot’
of the monetary consequences of drug consumption or production.
In this respect, we concur with Greenfield and Paoli (2012) that
“concerns about measurement are not wholly technical; they are
also normative” (p. 9).
First, social cost studies tend to underestimate the impact of
substance misuse, since they do not estimate the intangible costs,
such as pain, suffering, and loss of life (Moore & Caulkins, 2006;
Single et al., 2003) and these represent an important share of the
social cost of substance (mis)use. The current study estimated that
16% of all DALYs are caused by substances. Furthermore, Anderson
and Baumberg (2006) indicated that the intangible cost of alcohol
dependence and alcohol related crime accounts for more than 68%
of the social cost of alcohol in Europe. However, Tonry (2015), for
example, criticised the use of intangible “social costs of criminal
victimisation” to legitimise unjust ‘thought on crime approaches’.
Fundamentally, a balanced substance policy cannot be solely based
on social cost studies. These studies run the risk of being misused
for policy means because money is the common metric to place
various benefits and costs on a common footing (Dominguez &
Raphael, 2015).
Second, the social costs studies, including this one, do not
estimate the cost for all of the consequences of substance (mis)use
(Melberg, 2010). This is the case for unstable housing and
homelessness (Galea & Vlahov, 2002; Havinga, van der Velden,
de Gee, & van der Poel, 2014; Sumnall & Brotherhood, 2012), drugrelated corruption on human welfare, institutional instability
created by illegal drug production, and other adverse effects such
as environmental pollution due to cultivation and production of
illegal drugs (e.g. the harvesting of illicit crops can lead to soil
degradation, Pérez-Gómez & Wilson-Caicedo, 2000; UNODC, 1994)
(Singer, 2008; Single et al., 2003). Even more so, relying solely on
social cost studies for decision making is hazardous since these
studies might overestimate the costs associated with substances
because all of the associated costs are included in the estimate,
muddling consequences and causes.
55
Finally, a social cost study does not analyse the driving forces
that cause a problematic drug situation. They do not analyse life
domains such as social inequality, financial difficulties, unstable
housing and homelessness (Chalmers & Ritter, 2011; Costa Storti,
De Grauwe, Sabadash, & Montanari, 2011; Sumnall & Brotherhood,
2012; UNODC, 2016) that may have induced substance (mis)use.
Nor do they take into account that poverty and food insecurity are
the key factors that lead to the illicit cultivation of crops for the
production of illicit drugs. Dávalos et al. (2011), for example, found
that coca cultivation increases the probability of forest conversion,
but coca is not necessarily the cause of deforestation. They
concluded that other factors such as socioeconomic inequality,
failed agricultural development policies and armed conflict are the
most important drivers of deforestation. Consequently, social cost
studies cannot advise on strategies to overcome these root causes
(UNODC, 2016). In 2011, UNODC stated that the “adoption of
sustainable livelihood approaches could make an important contribution to the long-term success of prevention, treatment and
rehabilitation interventions in efforts to prevent drug abuse, HIV/
AIDS and crime” (UNODC, 2011, p. 14). Knowing that drug control
policies tend to focus on the consequences rather than on the
multitude of causes (Chouvy, 2013), means that tackling key
mechanisms of the drug problem remains the biggest challenge for
any drug policy.
Acknowledgement
This work was supported by the Belgian Science Policy Office
(BELSPO) in the framework of the Federal Research Programme
Drugs.
Conflict of interest
The authors declare no conflict of interest.
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