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- Two recent societal cost-benefit analyses have documented the costs of smoking and the cost-effectiveness of preventing smoking.- Smoking costs the Netherlands society EUR 33 billion per year.- The majority of this is the monetary value of health loss; these are "soft" euros that cannot be re-spent.- There is not a great deal of difference between costs and benefits when expressed in "hard" euros, which means that there is no clear business case for anti-smoking policy.- The greatest benefit of discouraging smoking is improved health for the individual and increased productivity for the business sector; however, the benefits cannot be easily realised, because even in the most favourable scenario the number of smokers will decrease slowly.- Excise duties seem to offer the most promising avenue for combating smoking. The benefits of anti-smoking policy, therefore, consist mainly of tax revenues for the government.- Stringent policy is required to transform tax revenues into health gains.

Health care costs have increased due to population ageing. It is often said that the majority of health care spending occurs in the last year of life and that, as a result, the total costs of population ageing are considerably lower than is usually predicted. With the Netherlands facing a rapidly ageing population, such statements are well-received by policy makers. Unfortunately they reflect only part of the truth and are therefore misleading. Nevertheless, health care costs in the last years of life are still interesting, but for a different reason than is widely believed. Taking a lifetime perspective, these costs shed new light on solidarity in health care.

Increasing healthcare costs force policy makers to make difficult choices in the insurance package. In order to make rational choices, there must be an understanding of the healthcare costs as well as the value of the health that the care provides. Health economists have in recent years carried out extensive research into the value that people attribute to health. Health is of great social value, and is difficult to express in concrete monetary terms. One extra life-year in good health ('quality-adjusted life year', QALY) seems to be valued on average at no less than 50,000 euros by people. Methodology needs to be developed in this area so that study results are more uniform and can be better compared. Physicians and policy makers will thus gain more insight into the value of health.

Objective: To estimate the costs of health care in 1994, the development of the costs assigned to specific diseases, and the future costs., Design: Descriptive., Setting: Erasmus University, Department of Public Health, Rotterdam, the Netherlands., Method: For each health care sector, costs were allocated to 62 diagnostic groups, age and sex making maximal use of national registries and other sources with data on health care use in the Netherlands., Results: More than 80% of the 60 billion Dutch guilders that were spent on health care in 1994 could be assigned to specific diseases. Most costs were made for non-fatal diseases like mental deficiency, dementia and musculoskeletal disease. Except for cardiovascular disease, the share of major causes of death in the total costs was not significant. Average costs per inhabitant were low during youth and adulthood but increased exponentially with age from age 50 onwards. Between 1988 en 1994, health care costs experienced an annual growth rate of 5.2%, caused by price and wage increases (one half), ageing (a quarter) and other effects on health care costs such as epidemiological and technological change (a quarter)., Conclusion: The main determinants of health care use in the Netherlands were old age and disabling conditions. Due to ageing and other influences, real health care costs in the years to come will increase by an average annual rate of 2.4%.

Objective: To determine whether compression ultrasound examination of both legs, to detect deep venous thrombosis, can be the examination of first choice in patients clinically suspected of pulmonary embolism, assuming that the therapy of thrombosis is the same as the therapy of embolism., Design: Prospective study., Setting: St. Clara Hospital, Rotterdam, the Netherlands., Methods: 337 consecutive patients (157 women and 180 men, mean age 65 years, SD: 17.4) suspected of pulmonary embolism underwent compression ultrasound examination of the femoral and popliteal veins to detect deep venous thrombosis, and perfusion lung scintigraphy, with ventilation scintigraphy if indicated. Ultrasound examinations and lung scans were interpreted independently and blinded. A financial analysis of the various strategies was made., Results: Deep venous thrombosis was demonstrated ultrasonographically in four (2%) of 208 patients with a normal lung scan, in four (9%) of 43 patients with a non-diagnostic lung scan, and in 30 (35%) of 86 patients with a high probability lung scan. By starting the diagnostic investigation with ultrasound examination 38 lung scans and chest X-rays would be saved at the cost of 294 extra ultrasound examinations. Because ultrasound examinations are relatively inexpensive a cost reduction of 3.4% would be realised, for the Netherlands approximately 1.4 million guilders. In the United States, however, costs would increase because of the high prices of ultrasound examinations., Conclusion: Compression ultrasound examination of both legs can be the examination of first choice in the Netherlands in patients suspected of pulmonary embolism, as it is cost effective.