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

Joseph Menzin; Lisa M Lines; Jeno Marton


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

In This Article

Short-term Cost Impact of Smoking Cessation

The onset of smoking-related disease may prompt smoking cessation but may also increase the use of health services. After quitting, former smokers may seek medical care they had delayed while they were smokers, resulting in increased healthcare utilization.[30] Elevated healthcare use is often a predictor of a smoking-cessation attempt in the following year.[20,30,31] In observational studies, hospitalization rates for quitters increase in the short term, but decline over the subsequent 4-10 years to a rate at or below that of continuing smokers.[30,32] Increased hospital usage in the first year after quitting smoking is more likely to be a cause of smoking cessation than a consequence.[30]

Healthcare costs typically increase steadily for 2 years before a smoking-cessation attempt. The commonly seen spike in costs during the first quarter after quitting may be related to acute health events that often prompt a cessation attempt.[33] In all age categories, smokers incur higher healthcare costs than do nonsmokers; among 65-74-year-old individuals, male smokers may incur costs up to 40% higher than those of nonsmokers of the same age, whereas for women, the costs may differ by up to 25%.[34] As with utilization, quitters have increased costs in the short term, which appears to reflect the fact that those who quit may be doing so after a smoking-related illness.[33,35,36] Costs for quitters tend to decline after approximately 2-5 years.[35]

Employers incur smoking-related indirect costs because of workplace absenteeism and lost productivity. In a US study, annual absenteeism for smoking-related illness was found to be approximately 1.6 days lower for former smokers than for current smokers, although rates are still higher for former smokers than for never smokers. These results may not be generalized outside of the USA, given differences in other countries related to sick leave and holiday pay. Nonetheless, absenteeism has been shown to continue to decline in the years after smoking cessation in both US and Australian studies.[37,38] As with healthcare costs and utilization, productivity is worse for quitters during the first year after cessation, but quitters are more productive than current smokers 1-4 years after quitting.[39]

Approximately 6-7% of smokers per year typically use smoking-cessation insurance benefits, at a per-member-per-month cost of approximately US$0.14.[40] The 1-year return on investment ranges from 138 to 858%,[41] and less-intensive smoking-cessation interventions have a break-even point at 1 year, whereas more-intensive interventions have a 2:1 cost-benefit ratio.[42]

Past studies[41,42,44,45] have frequently referenced a paper, published in 1989, that drew from epidemiologic studies but contained a number of flawed and/or out-of-date assumptions.[43] For example, some of the cost to employers has been attributed to exposure to second-hand smoke, but more than 90% of all workers in the USA are now employed at establishments that have official smoking restriction policies.[69,70] In addition, a lack of data on absenteeism and productivity for recent quitters has required a number of models to make assumptions about potential improvements from smoking cessation. For example, several studies[41,42,46,71] have used Warner et al.'s outdated figure (based on data from an unreferenced year of the National Health Interview Survey) of 3.9 excess sick days for male smokers and 2.1 days for females, relative to never smokers.[47] The most recent data from the National Health Interview Survey, 2006, suggest that, relative to never smokers, current smokers take an excess of 2.8 sick days for males and 3.1 days for females.[69] By contrast, Fellows et al. assumed a 25% reduction in excess sick days for every year after quitting.[71] In the Javitz et al. model, absenteeism was reduced by the full differential amount in the first year after smoking cessation.[46] Another model assumed that the cost of absenteeism is 1% of a current smoker's salary.[48]

Regarding productivity, the Fellows model assumes an excess of 5 min per day of break time for smokers, reduced to zero after quitting.[48,71] The Levy et al. model assumes 25% higher healthcare expenditures for the smoking population, decreasing by 20% each year after quitting.[48] The Warner et al. model assumed that current smokers' healthcare costs are 32% higher than never smokers' costs, regardless of age, and that costs fall proportionately after quitting relative to the decline in mortality risk for former smokers.[49] The assumptions used in these models indicate a pressing requirement for more research on sick time, productivity and healthcare costs for quitters by time since quitting.

In modeling studies, smoking cessation has been projected to reduce utilization of health resources and associated costs to the healthcare system. For example, a 1% decrease in the number of pregnant women who smoke would prevent 1300 low birthweight births and approximately US$21 million in associated medical costs in the first year. After 7 years, those numbers would rise to 57,200 prevented low birthweight births and US$572 million in medical cost savings.[50] The CDC recommends limiting children's exposure to secondhand tobacco smoke, as it is associated with the development of asthma and can cause exacerbations among those who already have asthma.[51] These acute respiratory events can be costly from a payer perspective and can increase workplace absenteeism among primary caregivers of children with asthma. A 1% drop in smoking prevalence would prevent 1000 hospitalizations for AMI and 350 hospitalizations for stroke over 7 years in Australia.[52] In addition, a 7-year program reducing smoking rates by 1% per year would prevent 63,480 hospitalizations for AMI and 34,261 hospitalizations for stroke, could yield US$3.2 billion in medical cost savings, and prevent 13,000 deaths that occur before AMI and stroke patients arrive at the hospital.[53]


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