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Health economics economic assessments of interventions to promote smoking cessation

This section provides information on the economic assessments of interventions aimed at promoting smoking cessation. It discusses the impacts of cessation on individual smokers and the cost-effectiveness of various interventions such as tobacco excise tax increases, smoking bans, anti-smoking media campaigns, quitlines, pharmacotherapy, and more. The section also highlights the relationship between cigarette prices and smoking behavior, as well as the effectiveness of nicotine replacement therapy.

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Health economics economic assessments of interventions to promote smoking cessation

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  1. Health economicseconomic assessments of interventions to promote smoking cessation

  2. Heath Economics section

  3. Purpose • To provide information on economic assessments of interventions to promote smoking cessation.

  4. Evidence Base • Based on evidence presented largely in the other databases. • Strength of evidence statements therefore not given.

  5. Key Findings Impacts of Cessation • Smoking cessation reduces individual smokers’ risk of morbidity and mortality in the short and long terms • Smoking cessation is important for long-term improvements in workplace productivity, health care costs, and the public health • Jha P, Ramasundarahettige C, Landsman V, Rostron B, Thun M, Anderson RN, McAfee T, Peto R. 21st-Century hazards of smoking and benefits of cessation in the United States. N Engl J Med 2013;368:341-350. • Jha P, Peto R. Global effects of smoking, of quitting, and of taxing tobacco. N Engl J Med. 2014;370(1):60-8. Méndez D, Alshanqeety O, Warner KE. The potential impact of smoking control policies on future global smoking trends. Tobacco Control 2013;22(1): 46–51. Eriksen M, MacKay J, Ross H. The Tobacco Atlas, 4th ed. American Cancer Society, 2012. Halpern MT, Dirani R, Schmier JK. Impacts of a Smoking Cessation Benefit Among Employed Populations. J Occup Environ Med. 2007; 49(1): 11-21.

  6. Key Findings Cost-Effectiveness • Public health policies that promote smoking cessation are highly cost-effective. • Tobacco excise tax increases • Public and workplace smoking bans • Anti-smoking media campaigns • Quitlines and other cessation programs • Pharmacotherapy, including nicotine replacement therapy and prescription drugs Ranson MK, Jha P, Chaloupka FJ, Nguyen SN. The effectiveness and cost-effectiveness of price increases and other tobacco control policies. In Jha P, Chaloupka FJ, eds. Tobacco control in developing countries, 2000; pp.427-447 (Section V, Chapter 18). Ross H, Blecher E, Yan L, Hyland A. Do cigarette prices motivate smokers to quit? New evidence from the ITC survey. Addiction. 2011; 106(3): 609-619. Fichtenberg CM. Glantz SA. Effect of smoke-free workplaces on smoking behavior: systematic review. BMJ. 2002; 325: 188-191. Cornuz J, Gilbert A, Pinget C, McDonald P, Slama K, Salto E, Paccaud F. Cost-effectiveness of pharmacotherapies for nicotine dependence in primary care settings: a multinational comparison. Tob Control, 2006; 15(3): 152-159. Raw M, Mackay J, Reddy S. Time to take tobacco dependence treatment seriously. Lancet. 2016 Jan 30;387(10017):412-413.

  7. Key Findings Cigarette Prices • In general, tobacco excise tax increases raise cigarette prices • Among adults, higher cigarette prices reduce cigarette consumption by, • Inducing smoking cessation • Helping those who quit stay quit • Decreasing the number of cigarettes smoked by continuing users • Among young people, higher cigarette prices reduce initiation of regular smoking • Smoking in lower socioeconomic groups is more responsive to cigarette price increases than in higher economic groups Ross H, Kostova D, Stoklosa M, Leon M. The impact of cigarette excise taxes on smoking cessation rates from 1994 to 2010 in Poland, Russia, and Ukraine. Nicotine Tob Res. 2014; 16(S1): S37-43. Zhang B, Cohen J, Ferrence R, Rehm J. The impact of tobacco tax cuts on smoking initiation among Canadian young adults. Am J Prev Med. 2006; 30(6): 474-479. Blecher E, van Walbeek C. An Analysis of Cigarette Affordability. Paris: International Union Against Tuberculosis and Lung Disease; 2008. Kostova, D, Chaloupka, FJ, Shang, Ce. A duration analysis of the role of cigarette prices on smoking initiation and cessation in developing countries. European Journal of Health Economics. March 9, 2014.

  8. Key Findings Nicotine Replacement Therapy (NRT) • In clinical trials, use of NRT increases quit rates in the short term as well as promotes long term abstinence • Demand for NRT is… • inversely related to the demand for cigarettes • directly related to health insurance coverage • Inversely related to out-of-pocket cost • NRT consumption has decreased the demand for cigarettes • Patch and gum are among WHO’s Essential Medicines Stead LF, Perera R, Bullen C, Mant D, Hartmann-Boyce J, Cahill K, Lancaster T. Nicotine replacement therapy for smoking cessation. Cochrane Database of Systematic Reviews 2012, Issue 11. Art. No.: CD000146.pub4. Tauras JA, Chaloupka FJ. The demand for nicotine replacement therapies. Nicotine Tob Res. 2003; 5(2): 237-243. Solberg LI. Impact of insurance coverage on the use and effects of smoking cessation medications. Dis Manage Health Outcomes. 2005; 3(13): 151-158. World Health Organisation. Two forms of nicotine replacement therapy chosen as WHO "Essential Medicines". 17th Expert Committee on the Selection and Use of Essential Medicines. 2009.

  9. Key Findings Comprehensive Cessation Interventions • Community-based programs that use nurses and pharmacists are cost-effective in reducing tobacco use • Even brief advice by a trained physician increases the probability of a smoker quitting • Adequate, sustained funding for comprehensive tobacco control programs is effective at reducing smoking Rice VH, Hartmann-Boyce J, Stead LF. Nursing interventions for smoking cessation. Cochrane Database Syst Rev. 2013; 8: CD001188.pub4. Stead LF, Buitrago D, Preciado N, Sanchez G, Hartmann-Boyce J, Lancaster T. Physician advice for smoking cessation. Cochrane Database of Systematic Reviews 2013, Issue 5. Art. No.: CD000165.pub4. Farrelly MC, Pechacek TF, Thomas KY, Nelson D. The impact of tobacco control programs on adult smoking. Am J Public Health. 2008; 98(2): 304-309. Dobbie F, Hiscock R, Leonardi-Bee J, Murray S, Shahab L, Aveyard P, et al. Evaluating long-term outcomes of NHS stop smoking services (ELONS): a prospective cohort study. Health Technol Assess. 2015 Nov;19(95):1-156. Carson KV, Verbiest M, Crone MR, Brinn MP, Esterman AJ, Assendelft W, et al. Training health professionals in smoking cessation. Cochrane Database Syst Rev. 2012 May 16;(5):CD000214.

  10. Key Findings Establishing, Promoting, and Enforcing Comprehensive Smoke-free Policies Promote Smoking Cessation • Smoke-free environments encourage those who want to quit to succeed • Smoke-free homes encourage more quit attempts and increases the probability of abstaining from smoking among adult smokers • Smoke-free bars and restaurants decrease the probabilities of cessation relapse Frazer K, Callinan JE, McHugh J, van Baarsel S, Clarke A, Doherty K, et al. Legislative smoking bans for reducing harms from secondhand smoke exposure, smoking prevalence and tobacco consumption (review). Cochrane DB Syst Rev. 2016;(2):CD005992 Mills AL, Messer K, Gilpin EA, Pierce JP. The effect of smoke-free homes on adult smoking behavior: a review. Nicotine Tob Res. 2009;11(10):1131-41. Anger S, Kvasnicka M, Siedler T. One last puff? Public smoking bans and smoking behavior. J Health Econ. 2011;30(3):591-601.

  11. Key Findings Workplace Interventions • Providing workplace smoking cessation coverage leads to health and economic benefits for both employers and insurers • Workplace smoking bans reduce both smoking prevalence and smoking intensity • Workplace-based cessation programs constitute a cost-effective investment for employers Ross H. Economics of smoke free policies. In Lifting the smokescreen: 10 reasons for going smokefree. Smoke Free Partnership, March 2006. Fichtenberg CM. Glantz SA. Effect of smoke-free workplaces on smoking behavior: systematic review. BMJ. 2002; 325: 188-191. IARC. Evaluating the Effectiveness of Smoke-free Policies, IARC Handbook of Cancer Prevention, Volume 13, International Agency for Research on Cancer, World Health Organization, 2009. • Fichtenberg CM. Glantz SA. Effect of smoke-free workplaces on smoking behavior: a systematic review. BMJ. 2002; 325: 188-191. • Gera E Nagelhout, Marc C Willemsen, Bas van den Putte, Hein de Vries, Roy A Willems, Dewi Segaar. Effectiveness of a national reimbursement policy and accompanying media attention on use of cessation treatment and on smoking cessation: a real-world study in the Netherlands. Tob Control • 2015;24:455–461.

  12. Key Findings Quitlines • Quitlines effectively promote cessation across a wide variety of populations • Television, radio, web, and print media tobacco control advertising all increase calls to smokers’ quitlines • Multiple callbacks from quitlines increase long-term cessation rates • Offering free NRT through a quitline increases quitline utilization and quit rates Stead LF, Hartmann-Boyce J, Perera R, Lancaster T. Telephone counselling for smoking cessation. Cochrane Database Syst Rev. 2013 Aug 12;8:CD002850.pub3. Free C, Knight R, Robertson S, Whittaker R, Edwards P, Zhou W, Rodgers A, Cairns J, Kenward MG, Roberts I. Smoking cessation support delivered via mobile phone text messaging (txt2stop): a single-blind, randomised trial. Lancet. 2011; 378: 49–55. McAfee T, Davis KC, Alexander RL Jr, Pechacek TF, Bunnell R. Effect of the first federally funded US antismoking national media campaign. Lancet. 2013: S0140-6736(13)61686-4. Cummings KM, Fix B, Celestino P, Carlin-Menter S, O'Connor R, Hyland A. Reach, efficacy, and cost-effectiveness of free nicotine medication giveaway programs. J Public Health Manag Pract. 2006; 12(1): 37-43. Anita Lal, Cathy Mihalopoulos, Angela Wallace, Theo Vos. The cost–effectiveness of call-back counseling for smoking cessation. Tob Control 2014;23:437–442

  13. Key Findings Vulnerable Populations • Cessation programs for patients with smoking-related health problems are very cost effective • Reductions in smoking can reduce health disparities between the rich and the poor • Targeted programs encouraging smoking cessation in pregnant women are highly cost-effective • Living in an economically deprived area can increase the difficulty of quitting smoking • Individual smokers suffer economic hardship as a result of smoking Brown T, Stephen Platt, and Amanda Amos; Equity impact of European individual-level smoking cessation interventions to reduce smoking in adults: a systematic review. Eur J Public Health 2014 24: 551-556 Siahpush M, Wakefield MA, Spittal MJ, Durkin SJ, Scollo MM. Taxation reduces social disparities in adult smoking prevalence. Am J Prev Med. 2009; 36(4): 285-291. Hosseinpoor AR, Parker LA, Tursand'Espaignet E, Chatterji S. Socioeconomic inequality in smoking in low-income and middle-income countries: results from the World Health Survey. PLoS One. 2012;7(8):e42843. Chamberlain C, O'Mara-Eves A, Oliver S, Caird JR, Perlen SM, Eades SJ, Thomas J. Psychosocial interventions for supporting women to stop smoking in pregnancy. Cochrane Database Syst Rev. 2013; 10: CD001055.pub4. Christiansen B, Reeder K, Hill M, Baker TB, Fiore MC. Barriers to effective tobacco-dependence treatment for the very poor. J Stud Alcohol Drugs. 2012; 73(6): 874-84. John RM, Ross H, Blecher E. Tobacco expenditures and its implications for household resource allocation in Cambodia. Tob Control. 2012 May;21(3):341-6.

  14. Recommendations • Evidencebased population-level and low-cost individual-level interventions should be used to aid cessation, because they highly cost-effective • Comprehensive evidence-based cessation interventions should be covered under all health insurance plans • Smoking cessation services should be available to population groups with high tobacco use prevalence • e.g. low income, less educated, those with a mental illness • Interventions must be tailored to reach high-risk populations.

  15. Recommendations (cont.) • NRT should be available and affordable for general sale, as it is a viable and cost-effective cessation aid • The impact of strategies used by smokers to reduce their out-of-pocket expenses on their motivation to quit and their quit success rate should be evaluated • Simple briefs outlining the social and economic benefits of smoking cessation should be created and disseminated among decision-makers

  16. Areas for future research • Assess economic aspects of smoking cessation interventions globally, especially in low- and middle-income countries • Determine what can motivate smokers to try to quit more often; is there a tobacco product price point that would escalate the demand for cessation?; • Study the cost-effectiveness of youth smoking cessation using novel methods such as Internet and mobile-based cessation interventions • Study the impact of product price variation on motivation for cessation and successful quitting • Assess price and income elasticities of demand for cessation services in developed and developing countries

  17. Areas for future research (cont.) • Examine the relationship between higher nicotine dependence and price sensitivity or successful cessation • Study peer and family effects on the demand for smoking cessation among young smokers • Study effects of e-cigarette uptake on smoking cessation • Study whether charging higher health insurance premiums is a sufficient motivator for smoking cessation • Examine the nature of the relationship between physical exercise and smoking cessation • Evaluate the effectiveness and the cost-effectiveness of tailor-made cessation approaches for high prevalence/hard to reach populations

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