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Health economics economic assessments of interventions to promote smoking cessation


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Title: Health economics economic assessments of interventions to promote smoking cessation


Health economicseconomic assessments of
interventions to promote smoking cessation
Heath Economics section
Chair Hana Ross Managing Director Research, American Cancer Society, USA
Frank Chaloupka Distinguished Professor Dept. of Economics University of Illinois, USA
Christine Godfrey Professor of Health Economics University of York, UK
Ken Warner Distinguished Professor University of Michigan, USA
Trevor Woollery Economist Centers for Disease Control and Prevention, USA
Ayda Yurekli Senior Economic Advisor World Health Organization, Tobacco Free Initiative, Switzerland
  • To provide information on economic assessments of
    interventions to promote smoking cessation.

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

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
2013368341-350. Méndez D, Alshanqeety O, Warner
KE. The potential impact of smoking control
policies on future global smoking trends. Tobacco
Control 201322(1) 4651. 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.
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
  • 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.
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.
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
  • Patch and gum are among WHOs 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.
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 physician increases the
    probability of a smoker quitting
  • Adequate, sustained funding for comprehensive
    tobacco control programs is effective at reducing

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.
Key Findings
  • Health Insurance and the Workplace
  • 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.
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
128CD002850.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 4955. 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.
Key Findings
  • Vulnerable Populations
  • Cessation programs for patients with
    smoking-related health problems are very cost
  • 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

Rigotti NA, Clair C, Munafò MR, Stead LF.
Interventions for smoking cessation in
hospitalised patients. Cochrane Database Syst
Rev. 20125CD001837.pub3. 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, Tursan
d'Espaignet E, Chatterji S. Socioeconomic
inequality in smoking in low-income and
middle-income countries results from the World
Health Survey. PLoS One. 20127(8)e42843. Chamber
lain 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 May21(3)341-6.
  • Effective population-based and low-cost
    individual-level interventions should be used to
    aid cessation
  • 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
  • e.g. low income, less educated, those with a
    mental illness
  • Interventions must be tailored to reach high-risk

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

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
  • Study the impact of tobacco excise tax structure
    and the resultant degree 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

Areas for future research (cont.)
  • Examine the relationship between higher nicotine
    dependence and price sensitivity or successful
  • Study peer and family effects on the demand for
    smoking cessation among young smokers
  • Study effects of e-cigarette uptake on smoking
  • Study whether charging higher health insurance
    premiums is a sufficient motivator for smoking
  • Examine the nature of the relationship between
    physical exercise and smoking cessation