Updated 22 August 2017

The high cost of coughs. Is it money well spent?

Sponsored: Coughs are very common, so does it matter if most people don’t seek medical advice for their cough?


Coughs are very common. Surveys suggest that at any one time, up to one in three children or adults is suffering from a cough.1 p1365a It’s not surprising then that coughs are among the most common complaints for which people seek medical advice.1 p1366a

A new cough is the third most common reason for visits to the general practitioner and up to around one in three people seeing a specialist chest physician does so because of a cough that is not getting better1-3 1. P1366a, 2 p1a; 3. p5bc; p75a

It is likely, though, that these people represent the tip of the iceberg as most people with a cough don’t seek medical help or advice for their symptoms at all.1 p1366a

So if most people don’t seek advice for their cough, does it matter?

Patients with chronic cough may cough hundreds or even thousands of times a day, and a chronic cough can persist for months or even years. 4 p1544a The physical and psychological impact and effect on day-to-day activities and social life can be enormous.

Coughs may be associated with significant discomfort including dizziness, retching, excessive sweating, aching and sometimes even urinary incontinence. Coughs interrupt sleep and can be a considerable cause of irritation to other family members. They may become embarrassing, causing some to feel self-conscious enough to consider changes to their daily routine.3 p77a, p76a

In children, coughs may be disruptive at school and during the night and are often a cause of parental anxiety.5 p1a In one study, mothers reported a concern their children could die from choking on phlegm or vomit.6

It’s not surprising then that even if they don’t seek help from their doctor, people with coughs do seek relief elsewhere. Last year, South Africans spent around half a billion rand on cough syrup medicines alone.7

Is this spending justified?

Not according to clinical trials.

In 2014, the Cochrane Institute, which regularly reviews available studies around medicine effectiveness and safety, reported that they could find no strong evidence illustrating the benefit of cough medicines for either children or adults. In particular, the cough syrups evaluated for coughs in children did not appear to show any benefit over placebos. 8 p2a,b

Over 20 years ago the American Academy of Paediatrics cautioned doctors to warn parents about the lack of benefit and potential dangers of some of these remedies.9 p2a

Is there anything that can be done to relieve the discomfort of a cough?

Taking half a teaspoon of honey before sleep has been shown to provide soothing relief from coughs related to upper airway infection and lead to better quality sleep for both children and their parents than some common cough syrups. Honey is also less expensive and a natural option.10 p790a, p788b

Sucking lozenges or sipping water may temporarily supress a cough, and the soothing anti-inflammatory effects of lozenges, syrups or even honey may at least temporarily relieve the sensations of throat irritation.4 p1547b But for many, it is the overproduction and accumulation of mucus or phlegm in the airways which is the cause of a cough.11 p23a

Furthermore, mucus that is not coughed up can become a breeding ground for bacteria, resulting in infection and serious illness.11 p23b For this type of productive (wet) cough, mucolytic medications like N-Acetylcysteine (NAC) are important, designed specifically to break down the mucus which is causing the cough so the body can reabsorb it and/or make it easier to cough out.

Mucolytics have been shown to assist in reducing cough in adults and children.11-14 11. p23b; 12.p131a, 132b; 13.p2a; 14. p1538a

Adding up the total costs of cough

It is clear that the costs of coughs for South Africans in financial terms are huge. In addition to the money spent on medicines which don’t necessarily work, one should also consider consultations with healthcare practitioners, loss of productivity at work and days of work and school missed.15 p1a,b

Since it is a symptom of a respiratory condition, the exact impact on work absenteeism attributable to cough may be difficult to determine. However, work absenteeism costs the SA economy around 12 to 16 billion rand per annum. Around 40% of all sick notes are cases without medical diagnosis – however acute bronchitis accounts for about 4%, and acute respiratory episodes account for an estimated 10% of absenteeism.16

Can these costs be curtailed?

One message that comes through loud and clear is that consumers need to be educated in order to make informed decisions when seeking relief from coughs. When mucus is a problem, adhering to proven and effective treatments such as mucolytics, which address the underlying cause and thin the mucus effectively, may ensure money is better spent.

1. Chung KF, Pavord ID. Prevalence, pathogenesis and causes of chronic cough. Lancet 2008; 371: 1364-1374.
2. Fashner J, Ericson K, Werner S. Treatment of the common cold in children and adults. Am Fam Physician 2012; 86(2): 153-159.
3. Chung KF, Widdicombe JG, Boushey HA (Eds). Cough: Causes, machanisms and therapy. Oxford; UK: Blakwell Publishing Ltd, 2003.
4. Smith JA, Woodcock A. Chronic cough. N Engl J Med 2016; 375: 1544-1551.
5. Shields MD, Bush A, Everard ML, et al. Recommendations for the assessment and management of cough in children. Thorax 2007; 2008; 63(Suppl III): iii1-iii15.
6. Cornford CS, Morgan M, Ridsdale L. Why do mothers consult when their children cough? Fam Pract 1993; 10(2): 193-196.
7. R5C Systemic Liquid Market, Global IMS Data (Schedule 2 and below), November 2016.
8. Smith SM, Schroeder K, Fahey T. Over-the-counter (OTC) medications for acute cough in children and adults in community settings. Cochrane Database of Systematic Reviews 2014, Issue 11. Art. No.: CD001831. DOI: 10.1002/14651858.CD001831.pub5.
9. Gunn VL, Taha SH, Liebelt EL, Serwint JR. Toxicity of over-the-counter cough and cold medications. Pediatrics 2001; 108: e52. DOI: 10.1542/peds.108.3.e52
10. Shadkam MN, Mozaffari-Khosravi H, Mozayan MR. A comparison of the effect of honey, dextromethorphan, and diphenhydramine on nightly cough and sleep quality in children and their parents. J Alt Comp Med 2010; 16(7): 787-793.
11. Dhar R. Role of mucolytics in wet cough. J Ass Phys India 2013; 61 (Suppl): 23-27.
12. Sadowska AM. NAC mucolysis in the management of COPD. Ther Adv Resp Dis 2012; 6(3): 127-135.
13. Chalumeau M, Duijvestijn YCM. Acetylcysteine and carbocysteine for acute upper and lower respiratory tract infections in paediatric patients without chronic broncho-pulmonary disease. Cochrane Database of Systematic Reviews 2013, Issue 5. Art. No.: CD003124. DOI: 10.1002/14651858.CD003124.pub4.
14. De Flora S, Grassi C, Carati L. Attenuation of influenza-like symptomatology and improvement of cell-mediated immunity with long-term N-acetylcysteine treatment. Eur Resp J 1997; 10: 1535-1541.
15. Morice A, Kardos P. Comprehensive evidence-based review on European antitussives. BMJ Open Resp Res 2016; 3: e000137. DOI: 10.1136/bmjresp-2016-000137
16. Occupattional Care South Africa. Absenteeism Management. Available at: Accessed 7 February 2017.


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Professor Keertan Dheda has received several prestigious awards including the 2014 Oppenheimer Award, and has published over 160 peer-reviewed papers and holds 3 patents related to new TB diagnostic or infection control technologies. He serves on the editorial board of the journals PLoS One, the International Journal of Tuberculosis and Lung Disease, American Journal of Respiratory and Critical Medicine, Lancet Respiratory Diseases and Nature Scientific Reports, amongst others. Read his full biography at the University of Cape Town Lung Institute.

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