Estimating the Short-term Clinical and Economic Benefits of Smoking Cessation: Do We Have it Right?

Joseph Menzin; Lisa M Lines; Jeno Marton

Disclosures

Expert Rev Pharmacoeconomics Outcomes Res. 2009;9(3):257-264. 

In This Article

Abstract and Introduction

Abstract

Smoking cessation is cost effective from a long-term perspective, but less is known about its short-term cost-effectiveness. Short-term health benefits are clear for certain groups, such as cardiovascular patients, pregnant women and patients undergoing surgery. Smoking cessation reduces overall mortality, cardiovascular mortality and cancer-related mortality within 5 years of quitting, and, in some cases, the risks are reduced to the levels of never smokers. In this article, conducted from a USA policy perspective, we found some evidence of the clinical and economic benefits of smoking cessation in the short term, which could be incorporated into cost-effectiveness studies. Nonetheless, the policy and social welfare implications of a short-term focus must be carefully evaluated, considering the established favorable long-term cost-effectiveness of smoking cessation.

Introduction

According to the US CDC, approximately 20% of US adults were current smokers in 2006.[66] Among smokers, approximately 44% attempt to quit each year.[66] The USA Surgeon General reports that one in five deaths can be attributed to smoking, making it the leading cause of death and disease in the USA.[67]

Seven first-line smoking-cessation aides available in the USA have been shown to reliably increase long-term smoking-abstinence rates, including five nicotine and two non-nicotine products.[68] Numerous studies have documented the clinical benefits of quitting smoking[1,67] as well as the favorable cost-effectiveness of smoking cessation interventions.[2,3,4,5,6,7,8,9] In fact, smoking cessation is often considered the gold standard for cost-effective health interventions.[68] Despite the favorable clinical and economic benefits associated with strategies aimed at smoking cessation, government and private insurers have been reluctant to offer routine coverage for pharmacologic therapies. This, in turn, appears to lead to underuse of effective smoking-cessation aids. It has been shown that quitting attempts and smoking-abstinence rates increase with prepaid and discounted prescription smoking-aide benefits.[68] Making smoking-cessation treatment a covered benefit increases the likelihood that tobacco users will receive treatment and quit successfully.[10]

Some payers are reluctant to cover smoking-cessation interventions for a number of reasons, such as skepticism that users of smoking-cessation interventions will be enrolled long enough to permit an adequate return on investment, low perceived effectiveness in actual clinical practice and high budgetary impact, since over 20% of the population smokes in most Western countries.[11,12] Nevertheless, the most recent US Public Health Service guidelines for treating tobacco use and dependence recommend that all insurance plans include smoking-cessation counseling and medication as covered benefits.[68]

Solid and credible estimates of the true cost-effectiveness of smoking-cessation strategies from the viewpoint of various payers are needed to better inform policies concerning coverage and reimbursement. The purpose of this article is threefold:

  • To provide an overview of short-term clinical and economic effects of smoking cessation

  • To highlight methodologic and data gaps that need to be bridged to improve upon current estimates

  • To discuss how decisions regarding coverage and reimbursement for smoking-cessation treatments may affect public health

For this review, we identified papers published over the last four decades that assess the short-term cost-effectiveness of smoking cessation, defined in terms of cost per life-year gained or cost per additional quitter. We also included papers that evaluated the clinical and economic effects of quitting smoking in the short term. We arbitrarily defined 'short term' as less than or equal to 7 years. To be included, studies were required to compare either smokers or nonsmokers with quitters and were required to report outcomes for quitters by time since cessation. The reason for this requirement was to attempt to gather precise data on the short-term effects of smoking cessation. For example, it is often asserted that smokers take more sick days than nonsmokers; we wanted to focus on studies that showed whether quitters take fewer or more sick days than either continuing smokers or never smokers and whether this varied by time since quitting. Similarly, it was not enough for a study to demonstrate cost or health differences between a cohort of smokers, ex-smokers and never smokers if the study combined all ex-smokers (those who quit yesterday and those who quit 20 years ago) in the same study population together. Out of 709 articles identified in searches of PubMed, EMBASE and other electronic sources, 60 articles met our inclusion criteria and were reviewed. The review was primarily conducted from a USA policy perspective.

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