Development of the health and economic consequences of smoking interactive model

Economic research in waterpipe tobacco smoking: reflections on data, demand, taxes, equity and health modelling

Economic evaluation of tobacco control policies is common in high-income settings and mainly focuses on cigarette smoking. Evidence suggests that increasing the excise tax of tobacco products is a consistently effective tool for reducing tobacco use and is an efficient mechanism for increasing government revenues. However, less research has been conducted in low/middle-income countries where other tobacco forms are common. This paper presents insights from our work on the economics of waterpipe tobacco smoking conducted in the Eastern Mediterranean Region where waterpipe smoking originated and is highly prevalent. The specific areas related to economics of waterpipe smoking considered herein are: price elasticity, taxation, government revenue, expenditure and healthcare costs. This paper aims to provide practical guidance for researchers investigating the economics of waterpipe tobacco with potential implications for other novel tobacco products. We present lessons learnt across five thematic areas: data, demand, taxes, equity and health modelling. We also highlight knowledge gaps to be addressed in future research. Research implications include designing comprehensive assessment tools that investigate heterogeneity in waterpipe smoking patterns; accounting for cross-price elasticity of demand with other tobacco products; exploring the change in waterpipe tobacco smoking in response to a tax increase and analysing the equity impact of waterpipe tobacco control interventions.

Smoking cessation economic benefits in a human capital approach: emerging evidence in Jordan

Background: Smoking is a major cause globally of morbidity and mortality hence life years lost, this issue manifested in 399 Million Jordanian dinars (JD)($562.3 million USD) lost yearly due to productivity lost as a consequence of smoking in Jordan1. It is no surprise that quitting smoking will reduce the loss in life years and hence productivity. In this study, using cohort simulation, we want to quantify the gains in productivity from smoking cessation aids usage for one course of smoking cessation aid varenicline or nicotine replacement therapy in comparison to physician counseling only without pharmacological therapy, in the population that intends to quit at a point of time, through campaigns nationwide, among the working-age population followed up until retirement.

Methodology: We present a transparent, generic model based on accepted analytic methods that allow users to assess the present value of lifetime earnings gained (PVLE) in smokers who intend to quit. It is shown in previous studies that smoking cessation aids are cost-effective in Jordan (Madae’en et al. 2020), yet the benefit of using smoking cessation aids goes further to reduce productivity loss by reducing life years lost. Our model incorporates life-years gained from the Markov Model in Madae’en et al. (2020), simulation of Jordanian male smokers’ cohort in three scenarios of either using varenicline or nicotine replacement therapy or only physician consultation, to estimate life-years gained and hence reduction in lost productivity costs.

Results: We found productivity loss was reduced in males who attempted to quit in their productive years. Using Varenicline, the researchers calculated the expected future payments (wages) count for years gained due to varenicline use for a wage average of 507 JDs ($714.5 USD) per month discounted by 8% for the rest of their productive life. As well as for the other two scenarios, the gained productivity from one course of varenicline to the male adults over 30 who intend to quit will reduce loss by more than 72 billion JDs ($101.42 billion USD) among the working-age population followed up until retirement.

Conclusion: policy change must be approached to reimbursement of smoking cessation aid in the Jordanian formulary.

Cost-Effectiveness Analysis of Smoking Cessation Interventions With Behavioral Support: A Study Based on the Benefits of Smoking Cessation on Outcomes (BENESCO) Model

INTRODUCTION

Few studies have compared cost-effectiveness of different smoking cessation interventions (SCIs) that include behavioral support, considering smoking-related diseases. Therefore, we compare the cost-effectiveness of SCIs with behavioral support in South Korea using the Benefits of Smoking Cessation on Outcomes (BENESCO) model.

AIMS AND METHODS

We used the BENESCO model to estimate the cost and utility of the SCIs with behavioral support, including pharmacist counseling with nicotine replacement therapy (pharmacist+NRT), expert counseling with NRT (expert+NRT), and expert counseling with varenicline (expert+varenicline). The target population was adult smokers who wanted to cease smoking within 1 month. We applied transitional probabilities and epidemiological data from the literature. Medical costs and utilities were calculated using claims and national survey data, respectively. Cost-effectiveness was evaluated within the threshold (17 926 USD per quality-adjusted life years [QALYs]) by incremental cost-effectiveness ratio (ICER).

RESULTS

The model cohort included 1 219 390 male and 298 511 female smokers. The pharmacist+NRT group had 32 842 more QALYs gained and 26 689 958 USD less expended than the expert+NRT group. The ICER for the expert+varenicline group versus the pharmacist+NRT and expert+NRT groups was 27 247 and 4074 USD per QALY, respectively. The robustness of the results was confirmed by sensitivity analyses, except for the discount rate and cost of the expert+varenicline group.

CONCLUSIONS

In Korea, pharmacist counseling with NRT showed higher QALY gains and lower costs than expert counseling with NRT. Expert counseling with varenicline was more effective for smoking cessation and more cost-effective than expert counseling with NRT but was not cost-effective compared with pharmacist counseling with NRT.

IMPLICATIONS

This study provides evidence for decision-making on smoking cessation programs by evaluating the cost-effectiveness of SCIs. Furthermore, we attempted to use the BENESCO model to compare and evaluate the cost-effectiveness of SCIs with behavioral support. It is meaningful because this study showed the availability of using the BENESCO model in the future cost-effectiveness analysis of various SCIs.

Smoking cessation medicines and e-cigarettes: a systematic review, network meta-analysis and cost-effectiveness analysis

BACKGROUND

Cigarette smoking is one of the leading causes of early death. Varenicline [Champix (UK), Pfizer Europe MA EEIG, Brussels, Belgium; or Chantix (USA), Pfizer Inc., Mission, KS, USA], bupropion (Zyban; GlaxoSmithKline, Brentford, UK) and nicotine replacement therapy are licensed aids for quitting smoking in the UK. Although not licensed, e-cigarettes may also be used in English smoking cessation services. Concerns have been raised about the safety of these medicines and e-cigarettes.

OBJECTIVES

To determine the clinical effectiveness, safety and cost-effectiveness of smoking cessation medicines and e-cigarettes.

DESIGN

Systematic reviews, network meta-analyses and cost-effectiveness analysis informed by the network meta-analysis results.

SETTING

Primary care practices, hospitals, clinics, universities, workplaces, nursing or residential homes.

PARTICIPANTS

Smokers aged ≥ 18 years of all ethnicities using UK-licensed smoking cessation therapies and/or e-cigarettes.

INTERVENTIONS

Varenicline, bupropion and nicotine replacement therapy as monotherapies and in combination treatments at standard, low or high dose, combination nicotine replacement therapy and e-cigarette monotherapies.

MAIN OUTCOME MEASURES

Effectiveness - continuous or sustained abstinence. Safety - serious adverse events, major adverse cardiovascular events and major adverse neuropsychiatric events.

DATA SOURCES

Ten databases, reference lists of relevant research articles and previous reviews. Searches were performed from inception until 16 March 2017 and updated on 19 February 2019.

REVIEW METHODS

Three reviewers screened the search results. Data were extracted and risk of bias was assessed by one reviewer and checked by the other reviewers. Network meta-analyses were conducted for effectiveness and safety outcomes. Cost-effectiveness was evaluated using an amended version of the Benefits of Smoking Cessation on Outcomes model.

RESULTS

Most monotherapies and combination treatments were more effective than placebo at achieving sustained abstinence. Varenicline standard plus nicotine replacement therapy standard (odds ratio 5.75, 95% credible interval 2.27 to 14.90) was ranked first for sustained abstinence, followed by e-cigarette low (odds ratio 3.22, 95% credible interval 0.97 to 12.60), although these estimates have high uncertainty. We found effect modification for counselling and dependence, with a higher proportion of smokers who received counselling achieving sustained abstinence than those who did not receive counselling, and higher odds of sustained abstinence among participants with higher average dependence scores. We found that bupropion standard increased odds of serious adverse events compared with placebo (odds ratio 1.27, 95% credible interval 1.04 to 1.58). There were no differences between interventions in terms of major adverse cardiovascular events. There was evidence of increased odds of major adverse neuropsychiatric events for smokers randomised to varenicline standard compared with those randomised to bupropion standard (odds ratio 1.43, 95% credible interval 1.02 to 2.09). There was a high level of uncertainty about the most cost-effective intervention, although all were cost-effective compared with nicotine replacement therapy low at the £20,000 per quality-adjusted life-year threshold. E-cigarette low appeared to be most cost-effective in the base case, followed by varenicline standard plus nicotine replacement therapy standard. When the impact of major adverse neuropsychiatric events was excluded, varenicline standard plus nicotine replacement therapy standard was most cost-effective, followed by varenicline low plus nicotine replacement therapy standard. When limited to licensed interventions in the UK, nicotine replacement therapy standard was most cost-effective, followed by varenicline standard.

LIMITATIONS

Comparisons between active interventions were informed almost exclusively by indirect evidence. Findings were imprecise because of the small numbers of adverse events identified.

CONCLUSIONS

Combined therapies of medicines are among the most clinically effective, safe and cost-effective treatment options for smokers. Although the combined therapy of nicotine replacement therapy and varenicline at standard doses was the most effective treatment, this is currently unlicensed for use in the UK.

FUTURE WORK

Researchers should examine the use of these treatments alongside counselling and continue investigating the long-term effectiveness and safety of e-cigarettes for smoking cessation compared with active interventions such as nicotine replacement therapy.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42016041302.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 59. See the NIHR Journals Library website for further project information.

Cost-Effectiveness Analysis of Smoking Cessation Interventions in the United Kingdom Accounting for Major Neuropsychiatric Adverse Events

OBJECTIVES

Smoking is a leading cause of death worldwide. Cessation aids include varenicline, bupropion, nicotine replacement therapy (NRT), and e-cigarettes at various doses (low, standard and high) and used alone or in combination with each other. Previous cost-effectiveness analyses have not fully accounted for adverse effects nor compared all cessation aids. The objective was to determine the relative cost-effectiveness of cessation aids in the United Kingdom.

METHODS

An established Markov cohort model was adapted to incorporate health outcomes and costs due to depression and self-harm associated with cessation aids, alongside other health events. Relative efficacy in terms of abstinence and major adverse neuropsychiatric events was informed by a systematic review and network meta-analysis. Base case results are reported for UK-licensed interventions only. Two sensitivity analyses are reported, one including unlicensed interventions and another comparing all cessation aids but removing the impact of depression and self-harm. The sensitivity of conclusions to model inputs was assessed by calculating the expected value of partial perfect information.

RESULTS

When limited to UK-licensed interventions, varenicline standard-dose and NRT standard-dose were most cost-effective. Including unlicensed interventions, e-cigarette low-dose appeared most cost-effective followed by varenicline standard-dose + bupropion standard-dose combined. When the impact of depression and self-harm was excluded, varenicline standard-dose + NRT standard-dose was most cost-effective, followed by varenicline low-dose + NRT standard-dose.

CONCLUSION

Although found to be most cost-effective, combined therapy is currently unlicensed in the United Kingdom and the safety of e-cigarettes remains uncertain. The value-of-information analysis suggested researchers should continue to investigate the long-term effectiveness and safety outcomes of e-cigarettes in studies with active comparators.

Estimating the Population Health Impact of Recently Introduced Modified Risk Tobacco Products: A Comparison of Different Approaches

Introduction

Various approaches have been used to estimate the population health impact of introducing a Modified Risk Tobacco Product (MRTP).

Aims and Methods

We aimed to compare and contrast aspects of models considering effects on mortality that were known to experts attending a meeting on models in 2018.

Results

Thirteen models are described, some focussing on e-cigarettes, others more general. Most models are cohort-based, comparing results with or without MRTP introduction. They typically start with a population with known smoking habits and then use transition probabilities either to update smoking habits in the “null scenario” or joint smoking and MRTP habits in an “alternative scenario”. The models vary in the tobacco groups and transition probabilities considered. Based on aspects of the tobacco history developed, the models compare mortality risks, and sometimes life-years lost and health costs, between scenarios. Estimating effects on population health depends on frequency of use of the MRTP and smoking, and the extent to which the products expose users to harmful constituents. Strengths and weaknesses of the approaches are summarized.

Conclusions

Despite methodological differences, most modellers have assumed the increase in risk of mortality from MRTP use, relative to that from cigarette smoking, to be very low and have concluded that MRTP introduction is likely to have a beneficial impact. Further model development, supplemented by preliminary results from well-designed epidemiological studies, should enable more precise prediction of the anticipated effects of MRTP introduction.

Implications

There is a need to estimate the population health impact of introducing modified risk nicotine-containing products for smokers unwilling or unable to quit. This paper reviews a variety of modeling methodologies proposed to do this, and discusses the implications of the different approaches. It should assist modelers in refining and improving their models, and help toward providing authorities with more reliable estimates.

A systematic review of economic evaluations of local authority commissioned preventative public health interventions in overweight and obesity, physical inactivity, alcohol and illicit drugs use and smoking cessation in the United Kingdom

Background

Since 2013, local authorities in England have been responsible for commissioning preventative public health interventions. The aim of this systematic review was to support commissioning by collating published data on economic evaluations and modelling of local authority commissioned public health preventative interventions in the UK.

Methods

Following the PRISMA protocol, we searched for economic evaluations of preventative intervention studies in four different areas: overweight and obesity, physical inactivity, alcohol and illicit drugs use and smoking cessation. The systematic review identified studies between January 1994 and February 2015, using five databases. We synthesized the studies to identify the key methods and examined results of the economic evaluations.

Results

The majority of the evaluations related to cost-effectiveness, rather than cost-benefit analyses or cost-utility analyses. These analyses found preventative interventions to be cost effective, though the context of the interventions differed between the studies.

Conclusions

Preventative public health interventions in general are cost-effective. There is a need for further studies to support justification of continued and/or increased funding for public health interventions. There is much variation between the types of economically evaluated preventative interventions in our review. Broader studies incorporating different contexts may help support funding for local authority-sponsored public health initiatives.

Economic evaluation of smoking cessation in Ontario's regional cancer programs

Quitting smoking after a diagnosis of cancer results in greater response to treatment and decreased risk of disease recurrence and second primary cancers. The objective of this study was to evaluate the potential cost-effectiveness of two smoking cessation approaches: the current basic smoking cessation program consisting of screening for tobacco use, advice, and referral; and a best practice smoking cessation program that includes the current basic program with the addition of pharmacological therapy, counseling, and follow-up. A Markov model was constructed that followed 65-year-old smokers with cancer over a lifetime horizon. Transition probabilities and mortality estimates were obtained from the published literature. Costs were obtained from standard costing sources in Ontario and reports. Probabilistic and deterministic sensitivity analyses were conducted to address parameter uncertainties. For smokers with cancer, the best practice smoking cessation program was more effective and more costly than the basic smoking cessation program. The incremental cost-effectiveness ratio of the best practice smoking cessation program compared to the basic smoking cessation program was $3367 per QALY gained and $5050 per LY gained for males, and $2050 per QALY gained and $4100 per LY gained for females. Results were most sensitive to the hazard ratio of mortality for former and current smokers, the probability of quitting smoking through participation in the program and smoking-attributable costs. The study results suggested that a best practice smoking cessation program could be a cost-effective option. These findings can support and guide implementation of smoking cessation programs.

Cost-effectiveness analysis of metformin+dipeptidyl peptidase-4 inhibitors compared to metformin+sulfonylureas for treatment of type 2 diabetes

BACKGROUND

Patients with type 2 diabetes (T2D) typically use several drug treatments during their lifetime. There is a debate about the best second-line therapy after metformin monotherapy failure due to the increasing number of available antidiabetic drugs and the lack of comparative clinical trials of secondary treatment regimens. While prior research compared the cost-effectiveness of two alternative drugs, the literature assessing T2D treatment pathways is scarce. The purpose of this study was to evaluate the long-term cost-effectiveness of dipeptidyl peptidase-4 inhibitors (DPP-4i) compared to sulfonylureas (SU) as second-line therapy in combination with metformin in patients with T2D.

METHODS

A Markov model was developed with four health states, 1 year cycle, and a 25-year time horizon. Clinical and cost data were collected from previous studies and other readily available secondary data sources. The incremental cost-effectiveness ratio (ICER) was estimated from the US third party payer perspective. Both, costs and outcomes, were discounted at a 3% annual discount rate. One way and probabilistic sensitivity analyses were performed to evaluate the impact of uncertainty on the base-case results.

RESULTS

The discounted incremental cost of metformin+DPP-4i compared to metformin+SU was $11,849 and the incremental life-years gained were 0.61, resulting in an ICER of $19,420 per life-year gained for patients in the metformin+DPP-4i treatment pathway. The ICER estimated in the probabilistic sensitivity analysis was $19,980 per life-year gained. Sensitivity analyses showed that the results of the study were not sensitive to changes in the parameters used in base-case.

CONCLUSIONS

The metformin+DPP-4i treatment pathway was cost-effective compared to metformin+SU as a long-term second-line therapy in the treatment of T2D from the US health care payer perspective. Study findings have the potential to provide clinicians and third party payers valuable evidence for the prescription and utilization of cost-effective second-line therapy after metformin monotherapy failure in the treatment of T2D.

Need for implementation of pharmacoeconomics in healthcare system, case of analysis of antibiotic consumption in Republic of Macedonia for 2016

Pharmacoeconomics is new and modern health science, implemented in developed societies, to play core role in creating health policies. The main aim of pharmacoeconomic analysis is development of science methodology for evaluation of costs and outcomes of treatment, evaluation of economic parameters in the face of outcomes of clinical results, from different treatment options. Pharmaceutical companies implemented pharmacoeconomic principles for diversifying marketing approach and market access in pharmaceutical development. New healthcare systems demand increased costs for medical care, pharmaceutical products and medical devices. Process of medical costs for evaluation of costs evolved, indirect and hidden costs are part of sole process of evaluation. Health authorities from one side and pharmaceutical companies from other side developed unique methodologies for evaluation. With these implemented changes, traditional concept for evaluation of efficacy and safety of medical devices and pharmaceutical products was overbridged and pharmacoeconomics is base for research, development, registration, reimbursement, as well as dispensing and follow the life cycle of medicines. Results from antibiotic consumption analysis in Republic of Macedonia at 2016 showed that total antibiotic consumption and antibiotic consumption per DDD/1000 citizens is according to average EU trends, mostly similarly to the usage trends of low-income countries. But usage of new and innovative antibiotic is on very low level, which indicates the need of further implementing of pharmacoeconomic analysis and principles in decision making process, for improved health care for the patients. The ultimate goal of implementing the pharmacoeconomic system in each country is enhancing the benefit to the patient through improved resource allocation. Keywords: pharmacoeconomics, type of pharmacoeconomic analysis, antibiotic consumption, Republic of Macedonia

German EstSmoke: estimating adult smoking-related costs and consequences of smoking cessation for Germany

AIMS

We compared predicted life-time health-care costs for current, never and ex-smokers in Germany under the current set of tobacco control polices. We compared these economic consequences of the current situation with an alternative in which Germany were to implement more comprehensive tobacco control policies consistent with the World Health Organization (WHO) Framework Convention for Tobacco Control (FCTC) guidelines.

DESIGN

German EstSmoke, an adapted version of the UK EstSmoke simulation model, applies the Markov modelling approach. Transition probabilities for (re-)currence of smoking-related diseases were calculated from large German disease-specific registries and the German Health Update (GEDA 2010). Estimations of both health-care costs and effect sizes of smoking cessation policies were taken from recent German studies and discounted at 3.5%/year.

SETTING

Germany.

PARTICIPANTS

German population of prevalent current, never and ex-smokers in 2009.

MEASUREMENT

Life-time cost and outcomes in current, never and ex-smokers.

FINDINGS

If tobacco control policies are not strengthened, the German smoking population will incur €41.56 billion life-time excess costs compared with never smokers. Implementing tobacco control policies consistent with WHO FCTC guidelines would reduce the difference of life-time costs between current smokers and ex-smokers by at least €1.7 billion.

CONCLUSIONS

Modelling suggests that the life-time healthcare costs of people in Germany who smoke are substantially greater than those of people who have never smoked. However, more comprehensive tobacco control policies could reduce health-care expenditures for current smokers by at least 4%.

Modeling lifetime costs and health outcomes attributable to secondhand smoke exposure at home among Korean adult women

PURPOSE

The aim of this research is to estimate lifetime costs and health consequences for Korean adult women who were exposed to secondhand smoke (SHS) at home.

METHODS

A Markov model was developed to project the lifetime healthcare costs and health outcomes of a hypothetical cohort of Korean women who are 40 years old and were married to current smokers. The Korean epidemiological data were used to reflect the natural history of SHS-exposed and non-exposed women. The direct healthcare costs (in 2014 US dollars) and quality-adjusted life years (QALYs) were annually discounted at 5% to reflect time preference. The time horizon of the analysis was lifetime and the cycle length was 1 year. Deterministic and probabilistic sensitivity analyses were conducted.

RESULTS

In the absence of SHS exposure, Korean women will live 41.32 years or 34.56 QALYs before discount, which corresponded to 17.29 years or 15.35 QALYs after discount. The SHS-exposed women were predicted to live 37.91 years and 31.08 QALYs before discount and 16.76 years and 14.62 QALYs after discount. The estimated lifetime healthcare cost per woman in the SHS non-exposed group was US$11 214 before the discount and US$2465 after discount. The negative impact of SHS exposure on health outcomes and healthcare costs escalated as the time horizon increased, suggesting that the adverse impact of SHS exposure may have higher impact on the later part of the lifetime. The result was consistent across a wide range of assumptions.

CONCLUSION

Life expectancy might underestimate the impact of SHS exposure on health outcomes, especially if the time horizon of the analysis is not long enough. Early intervention on smoking behaviour could substantially reduce direct healthcare costs and improve quality of life attributable to SHS exposure.

[Cost-benefit of medical advice for quitting smoking in the Region of Murcia]

Objetivo

Realizar un análisis coste-utilidad del consejo médico para dejar de fumar en la Región de Murcia.

Diseño

Se realiza un análisis coste-utilidad del consejo médico para dejar de fumar versus la no intervención. Se utiliza un modelo de Markov para estimar los costes (en euros de 2014), bajo la perspectiva del financiador público, y los resultados en salud. Estos se medirán en años de vida ajustados por calidad (AVAC). El horizonte temporal del análisis es de 20 años, y los costes y resultados en salud se descontarán al 3%. Se realiza un análisis de sensibilidad determinístico univariante y multivariante.

Emplazamiento

Región de Murcia.

Participantes

Fumadores de la Región de Murcia.

Intervenciones

Consejo médico breve para dejar de fumar.

Mediciones principales

Años de vida ajustados por calidad (AVAC).

Resultados

Con un horizonte de 5 años (2018), el ratio coste-utilidad incremental se situaría en 172.400 € por AVAC ganado; con un horizonte de 10 años (2023), en 30.300 € por AVAC ganado, y con el horizonte máximo de 20 años considerado por el modelo, en 7.260 € por AVAC ganado.

Conclusiones

A largo plazo, el consejo breve médico es una intervención más eficiente que a corto plazo y, dependiendo del umbral coste-utilidad para España, se recomendaría su financiación pública desde el punto de vista de la eficiencia.

A conceptual framework for a long-term economic model for the treatment of attention-deficit/hyperactivity disorder

BACKGROUND

Models incorporating long-term outcomes (LTOs) are not available to assess the health economic impact of attention-deficit/hyperactivity disorder (ADHD).

OBJECTIVE

Develop a conceptual modelling framework capable of assessing long-term economic impact of ADHD therapies.

METHODS

Literature was reviewed; a conceptual structure for the long-term model was outlined with attention to disease characteristics and potential impact of treatment strategies.

RESULTS

The proposed model has four layers: i) multi-state short-term framework to differentiate between ADHD treatments; ii) multiple states being merged into three core health states associated with LTOs; iii) series of sub-models in which particular LTOs are depicted; iv) outcomes collected to be either used directly for economic analyses or translated into other relevant measures.

CONCLUSIONS

This conceptual model provides a framework to assess relationships between short- and long-term outcomes of the disease and its treatment, and to estimate the economic impact of ADHD treatments throughout the course of the disease.

Mathematical Modeling in Tobacco Control Research: Initial Results From a Systematic Review

OBJECTIVES

The US Food and Drug Administration has expressed interest in using mathematical models to evaluate potential tobacco policies. The goal of this systematic review was to synthesize data from tobacco control studies that employ mathematical models.

METHODS

We searched five electronic databases on July 1, 2013 to identify published studies that used a mathematical model to project a tobacco-related outcome and developed a data extraction form based on the ISPOR-SMDM Modeling Good Research Practices. We developed an organizational framework to categorize these studies and identify models employed across multiple papers. We synthesized results qualitatively, providing a descriptive synthesis of included studies.

RESULTS

The 263 studies in this review were heterogeneous with regard to their methodologies and aims. We used the organizational framework to categorize each study according to its objective and map the objective to a model outcome. We identified two types of study objectives (trend and policy/intervention) and three types of model outcomes (change in tobacco use behavior, change in tobacco-related morbidity or mortality, and economic impact). Eighteen models were used across 118 studies.

CONCLUSIONS

This paper extends conventional systematic review methods to characterize a body of literature on mathematical modeling in tobacco control. The findings of this synthesis can inform the development of new models and the improvement of existing models, strengthening the ability of researchers to accurately project future tobacco-related trends and evaluate potential tobacco control policies and interventions. These findings can also help decision-makers to identify and become oriented with models relevant to their work.

Cost-effectiveness of retreatment with varenicline after failure with or relapse after initial treatment for smoking cessation

OBJECTIVES

A recent trial showed the clinical benefit of retreatment with varenicline in subjects failing on the initial treatment, or relapsing after initial success. The objective of this study was to evaluate the cost-effectiveness of retreatment with varenicline compared with other smoking cessation interventions.

METHODS

A published Markov model was adapted to compare one quit attempt of varenicline followed by retreatment to treatment/retreatment with nicotine replacement therapy (NRT), bupropion or placebo, and with only 1 quit attempt of varenicline. Efficacy was obtained from clinical trials. Incidence of smoking-related diseases was based on published data. Cost of therapies and complications was obtained from databases and literature.

RESULTS

For 1000 smokers willing to quit, varenicline retreatment saves 275,000€, 118,000€, 316,000€ and 237,000€ compared to NRT, bupropion, placebo, or one single varenicline quit attempt respectively at lifetime and from the healthcare payer perspective. The number of quality adjusted life years gained is 74, 63, 193 and 111 respectively. Sensitivity analyses showed the robustness of these findings.

CONCLUSION

This analysis suggests that in the long term, varenicline retreatment is a dominant intervention, meaning both greater health gains and greater costs saved, over other possible interventions and therefore should be considered as a standard option.

Cost-effectiveness of varenicline versus bupropion, nicotine-replacement therapy, and unaided cessation in Greece

BACKGROUND

Varenicline was designed to relieve symptoms of nicotine withdrawal, including cigarette craving, and to block the reinforcing effects of continued nicotine use. The cost-effectiveness of varenicline in some countries has not been studied.

OBJECTIVE

The aim of this study was to compare the cost-effectiveness of varenicline to that of bupropion, nicotine-replacement therapy (NRT), and unaided cessation in the Greek health care setting. The analysis takes into account a societal security (third-party payer) perspective.

METHODS

To perform the analyses of the benefits of smoking cessation in terms of smoking-related morbidity, mortality, and associated medical costs, a Markov model was used that simulated the progress of a hypothetical cohort of current smokers making a single attempt to quit smoking at the beginning of the timeframe of the analysis. The robustness of the results was assessed using a series of 1-way sensitivity analyses.

RESULTS

Varenicline was associated with the potential prevention of 14.1, 14.2, and 35.1 additional cases of the 4 smoking-related diseases incorporated into the model, per 1000 smokers willing to quit, versus bupropion, NRT, and unaided cessation, respectively. Potentially avoided smoking-related deaths with varenicline were estimated at 3.24, 3.26, and 7.5 per 1000 quitters versus the 3 comparators. Varenicline led to a potential gain of 33.78, 33.91, and 83.97 QALYs per 1000 persons willing to make a quit attempt versus the 3 comparators. Varenicline was associated with cost-savings against both active comparators for the lifetime horizon. Overall, the cost per additional quitter with varenicline, considering only the costs of the smoking-cessation strategy, was €2659 (€1015) for a lifetime horizon compared with bupropion (NRT); however, when all direct costs were incorporated into the analysis, varenicline was cost-saving.

CONCLUSION

The findings from the present study suggest that, compared with the widely used treatment options bupropion and NRT, as well as unaided cessation, varenicline may enhance smoking-cessation treatment outcomes while substantially reducing the overall costs of smoking to the health care system.

Economic evaluation of smoking-cessation therapies: a critical and systematic review of simulation models

BACKGROUND

Smoking is probably the most important among preventable health risks. Health economic evaluation of smoking-cessation interventions, applying a lifetime perspective, is made possible by available epidemiological knowledge. The well established method of performing cost-effectiveness analyses of smoking-cessation interventions involves mathematical modelling (both deterministic and stochastic) of future events important for cost effectiveness.

OBJECTIVES

This study surveys cost-effectiveness analyses of smoking cessation, with a particular focus on the mathematical modelling and simulation analyses performed.

DATA SOURCES

A systematic literature search was performed using the databases MEDLINE, Econlit and Academic Search Complete.

STUDY SELECTION

Health economic evaluations, published as full-length journal articles, were searched for.

RESULTS

423 studies were identified and 78 were finally included, of which 30 were assessed as being highly relevant, based on the application of simulation modelling.

CONCLUSIONS

In general, studies are well performed as regards modelling. Common weaknesses include reporting of modelling details; validation of used simulation models; and the handling of structural uncertainty and different types of heterogeneity.

Systematic review of the cost-effectiveness of varenicline vs. bupropion for smoking cessation

The purpose of this systematic review was to review the cost-effectiveness of first-line non-nicotine therapies (varenicline and bupropion SR) for smoking cessation, identify differences in the models used and their conclusions of cost-effectiveness, and to determine which variables, if any, impact conclusions of cost-effectiveness. A systematic literature search was conducted in MEDLINE, PsychINFO, the National Health Service Economic Evaluation Database, the Health Technology Database and the Tufts Cost-effectiveness Analysis Registry from the earliest possible date through May 2011. To be included, studies had to compare cost-effectiveness of varenicline to bupropion using either a Markov model or discrete event simulation and be published as a full text manuscript in English or Spanish. Study selection and data extraction were done in duplicate with disagreement resolved through discussion. Data regarding the model characteristics, results and conclusions were extracted as were details to assess the quality of the study. Model characteristics and cost-effectiveness results were compared across studies and summarised qualitatively. Ten unique studies were included, all of which were Markov models. Eight studies used the Benefits of Smoking Cessation on Outcomes (BENESCO) model and all found varenicline to dominate bupropion. The two non-BENESCO models found varenicline to be cost-effective. Conclusions regarding the cost-effectives were changed upon sensitivity analysis with the following variables: time horizon, cost of bupropion, efficacy of either drug, age and the incidence of smoking related disease. Varenicline dominated bupropion in most cost-effectiveness models. However, applicability of models to clinical practice and variables which changed conclusion of cost-effectiveness should be considered in the interpretation of results.

Development and validation of a microsimulation economic model to evaluate the disease burden associated with smoking and the cost-effectiveness of tobacco control interventions in Latin America

OBJECTIVE

To describe the development and validation of a health economic model (HEM) to address the tobacco disease burden and the cost-effectiveness of smoking cessation interventions (SCI) in seven Latin American countries.

METHODS

The preparatory stage included the organization of the research network, analysis of availability of epidemiologic data, and a survey to health decision makers to explore country-specific information needs. The development stage involved the harmonization of a methodology to retrieve local relevant parameters and develop the model structure. Calibration and validation was performed using a selected country dataset (Argentina 2005). Predicted event rates were compared to the published rates used as model inputs. External validation was undertaken against epidemiologic studies that were not used to provide input data.

RESULTS

Sixty-eight decision makers were surveyed. A microsimulation HEM was built considering the availability and quality of epidemiologic data and relevant outcomes conceived to suit the identified information needs of decision makers. It considers all tobacco-related diseases (i.e., heart, cerebrovascular and chronic obstructive pulmonary disease, pneumonia/influenza, lung cancer, and nine other neoplasms) and can incorporate individual- and population-level interventions. The calibrated model showed all simulated event rates falling within ± 10% of the sources (-9%-+5%). External validation showed a high correlation between published data and model results.

CONCLUSIONS

This evidence-based, internally and externally valid HEM for the assessment of the effects of smoking and SCIs incorporates a broad spectrum of tobacco related diseases, SCI, and benefit measures. It could be a useful policy-making tool to estimate tobacco burden and cost-effectiveness of SCI.

A review of cost-effectiveness of varenicline and comparison of cost-effectiveness of treatments for major smoking-related morbidities

RATIONALE

This review aims to examine economic evaluations of varenicline, to compare the reported cost-effectiveness of varenicline with that of treatments for major smoking-related diseases and to evaluate the findings for decision making.

METHODS

A literature search was performed to identify published articles in English indexed in MEDLINE and the Cochrane Library (Issue 1, 2009), which includes the Economic Evaluation Database. Additional sources also were searched to identify unpublished varenicline studies, including conference abstracts. The search for varenicline studies was limited from 2006 to October 2009; searches for all other types of studies were limited from 1990 to October 2009.

RESULTS

The search yielded a total of 20 relevant economic evaluations of varenicline. In addition, 37 reviews of economic evaluations in chronic obstructive pulmonary disease, non-small cell lung cancer and cardiovascular disease, as well as studies evaluating the impact of economic rewarding were considered in this review. From these identified economic evaluations, the incremental cost-effectiveness ratios for varenicline ranged from dominance (more effective and cost saving) to €18,582 per quality-adjusted life-year (including indirect costs). These estimates appeared substantially lower when compared with incremental cost-effectiveness ratios reported for secondary prevention of smoking-related diseases, which in some cases were as high as €66,218 per quality-adjusted life-year.

CONCLUSIONS

Varenicline appears to be cost-effective from the perspective of both health care payers and employers, because of reduced health care consumption and costs. The cost-effectiveness of varenicline also compares favourably to that of interventions recommended for the treatment and prevention of smoking-related diseases.

Cost effectiveness of varenicline versus bupropion and unaided cessation for smoking cessation in a cohort of Finnish adult smokers

OBJECTIVE

To assess the cost effectiveness of varenicline compared with bupropion or unaided cessation for smoking cessation in Finnish adult smokers.

RESEARCH DESIGN AND METHODS

The BENESCO (BENEfits of Smoking Cessation on Outcomes) Markov model was used to follow a hypothetical cohort of smokers making a single quit attempt over a lifetime. Gender and age-specific data on the incidence and prevalence of five smoking-related diseases (chronic obstructive pulmonary disease [COPD], lung cancer, coronary heart disease [CHD], stroke and asthma exacerbations) were included in the model. Life-years (LYs), quality-adjusted life-years (QALYs), total treatment costs and the lifetime cumulative incidence of these parameters were the primary outcomes evaluated, and they were compared for varenicline versus bupropion and varenicline versus unaided cessation. The primary data were derived from Finnish publications and databases. Deterministic and probabilistic sensitivity analyses were performed to test the robustness of the base-case model.

RESULTS

The treatment cohort comprised 229 301 smokers making a quit attempt. In the lifetime simulation, use of varenicline prevented 1965 and 5057 additional cases of smoking-related disease, and 1184 and 3047 deaths attributable to smoking, when compared with bupropion and unaided cessation, respectively. Compared with bupropion and unaided cessation varenicline treatment yielded 4392 and 11 303 additional LYs (4851 and 12 485 QALYs), respectively. Varenicline resulted in cost savings of 15 million and 43 million euros (euro) compared with bupropion and unaided cessation, respectively. In the 20-year time horizon analysis, varenicline yielded an incremental cost-effectiveness ratio (ICER) of euro8791/QALY and euro7791/QALY gained in comparison to bupropion and unaided cessation, respectively. Sensitivity analyses supported the robustness of the base-case results for varenicline.

CONCLUSION

Varenicline dominated over its comparators, i.e. it was more effective and resulted in cost saving compared with bupropion and unaided cessation.

Crossing borders: factors affecting differences in cost-effectiveness of smoking cessation interventions between European countries

OBJECTIVES

Many different factors affect the transferability of cost-effectiveness results between countries. The objective is to quantify the impact of nine potential causes of variation in cost-effectiveness of pharmacological smoking cessation therapies (SCTs) between The Netherlands (reference case), Germany, Sweden, UK, Belgium, and France.

METHODS

The life-time benefits of smoking cessation were calculated using the Benefits of Smoking Cessation on Outcomes model, following a cohort of smokers making an unaided quit attempt, or using nicotine replacement therapy (NRT), bupropion, or varenicline. We investigated the impact of between-country differences in nine factors-demography, smoking prevalence, mortality, epidemiology and costs of smoking-related diseases, resource use and unit costs of SCTs, utility weights and discount rates-on the incremental net monetary benefit (INMB), using a willingness-to-pay (WTP) of euro20,000 per quality adjusted life year (QALY).

RESULTS

The INMB of 1000 quit attempts with NRT versus unaided, varies from euro0.39 million (Germany) to euro1.47 million (France). The differences between the countries were primarily due to differences in discount rates, causing the INMB to change between -65% to +62%, incidence and mortality rates (epidemiology) of smoking-related diseases (-43% to +35%) and utility weights. Impact also depended on the WTP for a QALY and time horizon: at a low WTP or a short time horizon, the resource use and unit costs of SCTs had the highest impact on INMB.

CONCLUSIONS

Although all INMBs were positive, there were significant differences across countries. These were primarily related to choice of discount rate and epidemiology of diseases.

The cost-effectiveness of an extended course (12+12 weeks) of varenicline compared with other available smoking cessation strategies in the United States: an extension and update to the BENESCO model

OBJECTIVES

This study aimed to estimate the cost-effectiveness of an extended (12+12 weeks) course of varenicline using the (Benefits of Smoking Cessation on Outcomes) BENESCO smoking cessation model.

METHODS

Data on the efficacy of 12+12 weeks varenicline therapy in aiding smoking cessation were analyzed in conjunction with the efficacy data for 12 weeks of varenicline, bupropion, and placebo previously included in the BENESCO model, by using a mixed treatment comparison. This analysis provided updated efficacy estimates for all the interventions, and these were used to update the model to estimate the relative cost-effectiveness of all smoking cessation interventions considered, now including 12+12 weeks of varenicline.

RESULTS

The updated 1-year abstinence estimates derived from the mixed treatment comparison were, for 12+12 weeks of varenicline, 12 weeks of varenicline, 12 weeks of bupropion, and 12 weeks of placebo, respectively: 27.7%, 22.9%, 15.9%, and 9.3%. The average cost of the course of 12+12 weeks of varenicline was estimated at $603.89, based on a 12-week course followed by a further 12 weeks for successful quitters. Over all subjects' lifetimes, 12+12 weeks of varenicline is less costly and more effective than (dominates) all other strategies compared in the updated BENESCO model, with the exception of 12 weeks of varenicline. In this comparison, 12+12 weeks of varenicline is a very cost-effective alternative to the 12-week course, with an incremental cost of less than $1000 per quality-adjusted life year (QALY) gained.

CONCLUSIONS

A total of 12 weeks of varenicline followed by a further 12-week course for successful quitters is a highly cost-effective alternative compared with currently available smoking cessation options.

Is a percentage a percentage? Systematic review of the effectiveness of Scandinavian behavioural modification smoking cessation programmes

INTRODUCTION

Tobacco smoke is the leading preventable cause of death in the world. A total of 50% of all smokers will die from a smoking-related disease with a major impact upon quality of life and health-care costs. Tobacco-controlling policies, including smoking cessation, have increasingly been implemented across European countries. Reported effectiveness data on smoking cessation interventions are important for decision making.

OBJECTIVE

This study aimed to conduct a literature review on how the effectiveness (quit rates) of behavioural modification smoking cessation programmes (BMSCPs) - counselling, quitlines and quit-and-win contests - were analysed in Denmark, Sweden and Norway.

METHODS

A systematic review was carried out by using the search engines Medline (U.S. National Library of Medicine, Bethesda, MD, USA), Cinahl (CINAHL Information Systems, EBSCO Industries, Ipswich, MA, USA), Embase (Elsevier, New York, NY, USA) and the grey literature. Following the Russell Standards, studies were selected according to design, analysis of data [intention-to-treat (ITT)/per protocol (PP)], documentation of abstinence and length of follow-up. Cochrane reviews of pharmacological studies were used as the benchmark.

RESULTS

Although ITT analysis is the standard scientific approach advocated, most studies of BMSCPs reviewed were analysed by using the PP approach and were based on self-reported point prevalence estimates. This resulted in the reported 1-year quit rates between 16%-45% (PP) and 9%-23% (ITT). In contrast, pharmacological studies are conservative, as they are randomised, use ITT analysis and have continuous quit rates with biochemical verification of abstinence.

CONCLUSION

This literature review reveals that quit rates of smoking cessation interventions are not always comparable. Scandinavian BMSCPs reported optimistic quit rates, confirmed by Cochrane literature review criteria. Care should be exercised when comparing smoking cessation interventions.

Varenicline: a pharmacoeconomic review of its use as an aid to smoking cessation

Varenicline (Chantix, Champix) is an orally administered alpha4beta2 nicotinic acetylcholine receptor partial agonist that is indicated as an aid to smoking cessation. Well designed clinical trials indicate that varenicline is an effective aid to smoking cessation. During the last 4 weeks of treatment, carbon monoxide-confirmed continuous abstinence rates were generally significantly higher with varenicline than with placebo, bupropion sustained release (SR) or nicotine replacement therapy. Varenicline also reduced cravings, the reinforcing effects of smoking and some withdrawal symptoms. Another well designed trial demonstrated that extending varenicline therapy by an additional 12 weeks helped maintain abstinence in individuals who had quit smoking. Varenicline was generally well tolerated in clinical trials; nausea, the most commonly occurring adverse event, diminished over time. More data are needed regarding the potential for neuropsychiatric events in varenicline recipients. Some of these events may be associated with nicotine withdrawal, rather than varenicline, although neuropsychiatric events have been observed in individuals who continued to smoke whilst receiving varenicline. In modelled cost-effectiveness analyses based on data from clinical trials in participants receiving smoking cessation therapy, 12 weeks' treatment with varenicline was predicted to be cost effective from a healthcare payer perspective in numerous countries. With regard to the incremental costs per QALY or life-year gained, 12 weeks' treatment with varenicline consistently dominated bupropion SR and nicotine replacement therapy and was dominant over or considered cost effective relative to unaided cessation, regular brief counselling or nortriptyline in analyses based on Markov models. In additional modelled analyses from a healthcare payer perspective, administering varenicline for an additional 12 weeks in participants who had successfully quit smoking was estimated to have acceptable incremental costs per QALY gained relative to varenicline for 12 weeks and to dominate other smoking cessation options. Moreover, in Swedish analyses that also included societal costs for production and consumption, the incremental cost per QALY gained for varenicline versus bupropion SR, and for an additional 12 weeks of varenicline therapy versus varenicline for 12 weeks only, was below commonly accepted thresholds of cost effectiveness. A US decision-analytic model from the perspective of various US health insurance plans demonstrated that, after 2 years, varenicline was predicted to dominate bupropion SR, in terms of the incremental cost per additional smoking cessation. Varenicline was also dominant or cost effective versus nicotine replacement therapy, and cost effective versus unaided cessation. Sensitivity analyses demonstrated that the results of cost-effectiveness studies were generally robust to plausible variations in key parameters. In conclusion, varenicline is an effective aid to smoking cessation. Varenicline was generally well tolerated in clinical trials, although more data are needed regarding the potential for neuropsychiatric events. The costs associated with varenicline are offset by direct savings associated with the reduction in smoking-related diseases. Despite their limitations, available pharmacoeconomic analyses from numerous countries support the use of varenicline for 12 or 24 weeks as a cost-effective treatment relative to other smoking cessation therapies in smokers who wish to quit smoking.

Cost-effectiveness of varenicline for smoking cessation

Smoking cessation therapies are among the most cost-effective preventive healthcare measures. Varenicline is a relatively new drug developed especially for this purpose, and it has been shown to achieve better quit rates than nicotine replacement therapies and the non-nicotine-based drug, bupropion, which has been in use for some years. The cost-effectiveness of varenicline depends on the cost of the therapy and the cost-savings achieved through reduced morbidity and mortality; several investigations, based on the situation in different countries, indicate that varenicline either finances itself fully through the cost-savings achieved or offers additional life-years at a lower price than that paid elsewhere in the healthcare sector.

Cost-utility analysis of varenicline, an oral smoking-cessation drug, in Japan

OBJECTIVE

To conduct a cost-utility analysis of two 12-week smoking-cessation interventions in Japan: smoking-cessation counselling by a physician compared with use of varenicline, an oral smoking-cessation drug, in addition to counselling.

METHODS

A Markov model was constructed to analyse lifetime medical costs and QALYs from the perspective of the healthcare payer. The cycle length was 5 years. Both costs and QALYs were discounted at 3% annually. The cohort of smokers was classified by sex and age, and we assumed that smokers started smoking at the age of 20 years and received smoking-cessation therapy at the ages of 30, 40, 50, 60 or 70 years (five separate models were run). The healthcare costs and QALYs were calculated throughout the term until the age of 90 years. In the base-case analysis, success rates of varenicline plus counselling and counselling alone were assumed to be 37.9% and 25.5%, respectively, in male smokers, and 22.2% and 16.1%, respectively, in female smokers, based on a randomized controlled trial conducted in Japan. Both univariate and probabilistic sensitivity analyses were conducted.

RESULTS

Prescribed varenicline was shown to be more effective and less costly than smoking-cessation counselling alone. Varenicline would save direct medical costs of Japanese Yen (yen)43 846 ($US381; $US1 = yen115; Oct 2007) and generate an increase of 0.094 QALYs in male smokers. In females the incremental cost-effectiveness ratio was yen346 143 per QALY gained. Varenicline is estimated to save yen23.7 billion ($US206 million) of the medical costs for tobacco-associated diseases for the whole population. Overall savings are yen9.5 billion. Sensitivity analyses suggested the robustness of the results.

CONCLUSIONS

As with any data of this nature, there is some uncertainty in the results and further research is warranted. However, based on the results of this pharmacoeconomic evaluation, varenicline, the first non-nicotine, oral treatment developed for smoking cessation, appears to be cost effective and may contribute to future medical cost savings in Japan.

Cost-utility analysis of varenicline versus existing smoking cessation strategies using the BENESCO Simulation model: application to a population of US adult smokers

BACKGROUND

Of 1 346 700 total deaths each year in the US, an estimated 440 100 are smoking related, making it the leading preventable cause of premature death in the US. Despite the health and economic benefits of smoking cessation being well documented, reimbursement coverage for smoking cessation therapies is generally limited in the US and elsewhere.

OBJECTIVES

To evaluate the cost effectiveness of varenicline, an alpha 4 beta 2 nicotinic acetylcholine receptor partial agonist, recently approved to aid smoking cessation.

METHODS

A Markov model, the Benefits of Smoking Cessation on Outcomes (BENESCO) model, was developed to simulate the lifetime direct costs and consequences of a hypothetical cohort of US adult smokers who make a one-time attempt to quit smoking. The smoking cessation strategies compared were varenicline, bupropion, nicotine replacement therapy and unaided quitting. The model used the hazard ratios from the Cancer Prevention Study (CPS)-II study for the mortality of smoking-related diseases as a proxy to calculate the relative risks of the incidence and prevalence of these diseases, following previously developed methodology. The costs (year 2005 values) and utilities for the included smoking-related diseases (lung cancer, chronic obstructive lung disease [COPD], coronary heart disease [CHD], stroke and asthma exacerbations), and the efficacies of the smoking cessation strategies, were sourced from the published literature. Costs and benefits were discounted at 3% pa. Probabilistic and univariate sensitivity analyses were conducted.

RESULTS

Varenicline was found to dominate all other smoking cessation strategies that were investigated for both the 20-year and lifetime timeframe. Furthermore, if 25% of the current population of US smokers made a one-time attempt to quit using varenicline compared with unaided cessation, almost 144 000 smoking-related deaths and over 261 000 cases of asthma exacerbations, COPD, CHD, stroke and lung cancer could be avoided compared with an unaided smoking cessation strategy.

CONCLUSIONS

Varenicline, a recently approved therapy for smoking cessation, is likely to be a cost-effective alternative compared with currently available options.

Cost-effectiveness of varenicline compared with bupropion, NRT, and nortriptyline for smoking cessation in the Netherlands

OBJECTIVE

To examine the cost-effectiveness of varenicline, a new pharmacotherapy to support smoking cessation, compared with the currently available pharmacologic alternatives in the Netherlands.

METHODS

The BENESCO-model was used to estimate the long-term health and economic benefits of smoking cessation for a cohort of smokers making a one-time quit attempt. The cohort represented the population of Dutch smokers with respect to gender, age, and prevalence of the smoking-related diseases included in the model: COPD, lung cancer, CHD, stroke, and asthma exacerbations. The model compared the cumulative incidence of smoking-related diseases, (quality-adjusted) life years, intervention costs, and direct medical costs between the cohort treated with varenicline and the same cohort either untreated (unaided cessation) or treated with bupropion, nortriptyline or NRT. The time horizon was lifetime. Future costs were discounted at 4%, health outcomes at 1.5%.

RESULTS

The cost of varenicline per additional quitter ranged from 1030 Euro compared with NRT to 4270 Euro compared with nortriptyline. When including the savings due to the reduction in incidence of smoking-related diseases, varenicline generated net savings compared with bupropion and NRT. Compared with nortriptyline and unaided cessation, varenicline was estimated to cost 1650 Euro/QALY and 320 Euro/QALY gained, respectively. At a willingness-to-pay as low as 5000/QALY gained, the probability that varenicline was cost-effective was more than 80% compared to bupropion, NRT, and unaided cessation and about 60% compared to nortriptyline.

CONCLUSION

Treatment with varenicline for smoking cessation is cost-effective compared with nortriptyline and unaided cessation and even cost-saving compared with bupropion and NRT.

The Quit Benefits Model: a Markov model for assessing the health benefits and health care cost savings of quitting smoking

Background

In response to the lack of comprehensive information about the health and economic benefits of quitting smoking for Australians, we developed the Quit Benefits Model (QBM).

Methods

The QBM is a Markov model, programmed in TreeAge, that assesses the consequences of quitting in terms of cases avoided of the four most common smoking-associated diseases, deaths avoided, and quality-adjusted life-years (QALYs) and health care costs saved (in Australian dollars, A$). Quitting outcomes can be assessed for males and females in 14 five year age-groups from 15–19 to 80–84 years.

Exponential models, based on data from large case-control and cohort studies, were developed to estimate the decline over time after quitting in the risk of acute myocardial infarction (AMI), stroke, lung cancer, chronic obstructive pulmonary disease (COPD), and death. Australian data for the year 2001 were sourced for disease incidence and mortality and health care costs. Utility of life estimates were sourced from an international registry and a meta analysis.

In this paper, outcomes are reported for simulated subjects followed up for ten years after quitting smoking. Life-years, QALYs and costs were estimated with 0%, 3% and 5% per annum discount rates. Summary results are presented for a group of 1,000 simulated quitters chosen at random from the Australian population of smokers aged between 15 and 74.

Results

For every 1,000 males chosen at random from the reference population who quit smoking, there is a an average saving in the first ten years following quitting of A$408,000 in health care costs associated with AMI, COPD, lung cancer and stroke, and a corresponding saving of A$328,000 for every 1,000 female quitters. The average saving per 1,000 random quitters is A$373,000. Overall 40 of these quitters will be spared a diagnosis of AMI, COPD, lung cancer and stroke in the first ten years following quitting, with an estimated saving of 47 life-years and 75 QALYs. Sensitivity analyses indicated that QBM predictions were robust to variations of ± 10% in parameter estimates.

Conclusion

The QBM can answer many of the questions posed by Australian policy-makers and health program funders about the benefits of quitting, and is a useful tool to evaluate tobacco control programs. It can easily be re-programmed with updated information or a set of epidemiologic data from another country.

Protocol for the smoking, nicotine and pregnancy (SNAP) trial: double-blind, placebo-randomised, controlled trial of nicotine replacement therapy in pregnancy

BACKGROUND

Smoking in pregnancy remains a public health challenge. Nicotine replacement therapy (NRT) is effective for smoking cessation in non-pregnant people, but because women metabolise nicotine and cotinine much faster in pregnancy, it is unclear whether this will be effective for smoking cessation in pregnancy. The NHS Health Technology Assessment Programme (HTA)-funded smoking, nicotine and pregnancy (SNAP) trial will investigate whether or not nicotine replacement therapy (NRT) is effective, cost-effective and safe when used for smoking cessation by pregnant women.

METHODS/DESIGN

Over two years, in 5 trial centres, 1050 pregnant women who are between 12 and 24 weeks pregnant will be randomised as they attend hospital for ante-natal ultrasound scans. Women will receive either nicotine or placebo transdermal patches with behavioural support. The primary outcome measure is biochemically-validated, self-reported, prolonged and total abstinence from smoking between a quit date (defined before randomisation and set within two weeks of this) and delivery. At six months after childbirth self-reported maternal smoking status will be ascertained and two years after childbirth, self-reported maternal smoking status and the behaviour, cognitive development and respiratory symptoms of children born in the trial will be compared in both groups.

DISCUSSION

This trial is designed to ascertain whether or not standard doses of NRT (as transdermal patches) are effective and safe when used for smoking cessation during pregnancy.

The role of public policies in reducing smoking prevalence in California: results from the California tobacco policy simulation model

Tobacco control policies are examined utilizing a simulation model for California, the state with the longest running comprehensive program. We assess the impact of the California Tobacco Control Program (CTCP) and surrounding price changes on smoking prevalence and smoking-attributable deaths. Modeling begins in 1988 and progresses chronologically to 2004, and considers four types of policies (taxes, mass media, clean air laws, and youth access policies) independently and as a package. The model is validated against existing smoking prevalence estimates. The difference in trends between predicted smoking rates from the model and other commonly used estimates of smoking prevalence for the overall period were generally small. The model also predicted some important changes in trend, which occurred with changes in policy. The California SimSmoke model estimates that tobacco control policies reduced smoking rates in California by an additional 25% relative to the level that they would have been if policies were kept at their 1988 level. By 2004, the model attributes 59% of the reduction to price increases, 28% of the overall effect to media policies, 11% to clean air laws, and only a small percent to youth access policies. The model estimates that over 5000 lives will be saved in the year 2010 alone as a result of the CTCP and industry-initiated price increases, and that over 50,000 lives were saved over the period 1988-2010. Tobacco control policies implemented as comprehensive tobacco control strategies have significantly impacted smoking rates. Further tax increases should lead to additional lives saved, and additional policies may result in further impacts on smoking rates, and consequently on smoking-attributable health outcomes in the population.

Repeated tobacco-use screening and intervention in clinical practice: health impact and cost effectiveness

BACKGROUND

This report updates 2001 estimates of disease burden prevented and cost effectiveness of tobacco-use screening and brief intervention relative to that of other clinical preventive services. It also addresses repeated counseling because the literature has focused on single episodes of treatment, while in reality that is neither desirable nor likely.

METHODS

Literature searches led to four models for calculating the clinically preventable burden of deaths and morbidity from smoking as well as the cost effectiveness of providing the service annually over time. The same methods were used in similar calculations for other preventive services to facilitate comparison.

RESULTS

Using methods consistent with existing literature for this service, an estimated 190,000 undiscounted quality-adjusted life years (QALYs) are saved at a cost of $1100 per QALY saved (discounted). These estimates exclude financial savings from smoking-attributable disease prevented and use the average 12-month quit rate in clinical practice for tobacco screening and brief cessation counseling with cessation medications (5.0%) and without (2.4%). Including the savings of prevented smoking-attributable disease and using the effectiveness of repeated interventions over the lifetime of smokers (23.1%), 2.47 million QALYs are saved at a cost savings of $500 per smoker who receives the service.

CONCLUSIONS

This analysis makes repeated clinical tobacco-cessation counseling one of the three most important and cost-effective preventive services that can be provided in medical practice. Greater efforts are needed to achieve more of this potential value by increasing current low levels of performance.

The cost utility of bupropion in smoking cessation health programs: simulation model results for Sweden

STUDY OBJECTIVES

To calculate incremental cost-utility ratios (cost per quality-adjusted life-year [QALY] gained) for bupropion (Zyban; GlaxoSmithKline; Gothenburg, Sweden), as compared to nicotine replacement therapy (NRT) in smoking cessation programs for a follow-up period of 20 years.

DESIGN

The Global Health Outcomes simulation model was used for a male cohort and for a female cohort as a point of departure but was further extended in order to include the following: (1) the indirect effects of smoking cessation on production and consumption in the economy, and (2) morbidity-specific QALYs gained.

SETTING

Sweden in 2001.

PATIENTS OR PARTICIPANTS

Model cohort consisting of 612,851 male and 780,970 female smokers, distributed by age, > or = 35 years old, as in the Swedish population of 2001.

INTERVENTIONS

Bupropion, as compared to NRT (nicotine patches and nicotine gums), in smoking cessation programs for a follow-up period of 20 years.

MEASUREMENTS AND RESULTS

When the indirect effects on production and consumption were taken into account, bupropion was cost saving in comparison to both NRTs. When only the direct costs were included, bupropion was still cost saving in comparison to nicotine gum. The incremental costs per QALY gained were relatively low for bupropion in comparison to nicotine patches, 6,600 Swedish kronas (SEK) (approximately 725 euro) per QALY gained for men and 4,900 SEK (approximately 535 euro) for women, all calculations in 2001 Swedish prices. The comprehensive sensitivity analysis showed robust results; results were, however, more sensitive to quit rates and intervention costs than to other variables.

CONCLUSIONS

Bupropion is a cost-effective therapy in smoking cessation programs. Furthermore, recent studies report even higher effectiveness in terms of quit rates than was assumed here, indicating that our estimated cost-utility ratio should be even more favorable to bupropion.

Simulation modeling and tobacco control: creating more robust public health policies

Although previous empirical studies have shown that tobacco control policies are effective at reducing smoking rates, such studies have proven of limited effectiveness in distinguishing how the effect of policies depend on the other policies in place, the length of adjustment period, the way the policy is implemented, and the demographic groups considered. An alternative and complementary approach to purely statistical equations is simulation models. We describe the SimSmoke simulation model and how we used it to assess tobacco control policy in a specific case study. Simulation models are not only useful for policy prediction and planning but also may help to broaden our understanding of the role of different public health policies within a complex, dynamic social system.

A model for cost-effectiveness analyses of smoking cessation interventions applied to a Quit-and-Win contest for mothers of small children

AIMS

The first aim of this study was to develop a model that predicts health and economic consequences of smoking cessation in Sweden, striving to follow the methodological recommendations to reflect the societal perspective and to use the health measure quality-adjusted life-years (QALYs). The second aim was to apply the model estimates to a smoking cessation intervention.

METHODS

A Markov cost-effectiveness model was developed on smoking-related lung cancer, chronic obstructive pulmonary disease, and cardiovascular disease. Swedish primary data on medical treatment costs and quality-of-life weights were used, supplemented with secondary data on other societal effects and the disease and death risks. The model simulations were applied to a "Quit-and-Win" contest for mothers of pre-school children. In total, 238 women participated, with 34 sustained tobacco-free at 12-month follow-up.

RESULTS

The cost-effectiveness model estimates a gain of 0.34 to 0.55 QALYs (discounted 3%), and cost savings of SEK 20-35,000 per female quitter in the age range 15 to 49 years. The cost-effectiveness analyses of the intervention showed intervention costs per quitter of SEK 7,850, and intervention costs per life-years saved (YLS) (discounted 3%) of SEK 13,200. The cost-utility analysis demonstrated cost savings and a gain of 16 QALYs.

CONCLUSIONS

The cost-utility analysis estimated health gains and cost savings resulting from the "Quit-and-Win" contest. As the model estimates on the differences in societal cost between smokers and quitters are considerable, many tobacco control programmes would result in cost savings. The construction of an optimal mix of tobacco control policies, however, demands incremental calculations on a range of programmes.

Cost-effectiveness of face-to-face smoking cessation interventions: a dynamic modeling study

OBJECTIVES

To estimate the cost-effectiveness of five face-to-face smoking cessation interventions (i.e., minimal counseling by a general practitioner (GP) with, or without nicotine replacement therapy (NRT), intensive counseling with NRT, or bupropion, and telephone counseling) in terms of costs per quitter, costs per life-year gained, and costs per quality-adjusted life-year (QALY) gained.

METHODS

Scenarios on increased implementation of smoking cessation interventions were compared with current practice in The Netherlands. One of the five interventions was implemented for a period of 1, 10, or 75 years reaching 25% of the smokers each year. A dynamic population model, the RIVM chronic disease model, was used to project future gains in life-years and QALYs, and savings of health-care costs from a decrease in the incidence of 11 smoking-related diseases over a time horizon of 75 years. This model allows the repetitive application of increased cessation rates to a population with a changing demographic and risk factor mix. Sensitivity analyses were performed for variations in costs, effects, time horizon, program size, and discount rates.

RESULTS

Compared with current practice, minimal GP counseling was a dominant intervention, generating both gains in life-years and QALYs and savings that were higher than intervention costs. For the other interventions, incremental costs per QALY gained ranged from about 1100 per thousand for telephone counseling to 4900 per thousand for intensive counseling with nicotine patches or gum for implementation periods of 75 years.

CONCLUSIONS

All five smoking cessation interventions were cost-effective compared with current practice, and minimal GP counseling was even cost-saving.

The cost-effectiveness of the English smoking treatment services: evidence from practice

AIMS

To investigate the cost-effectiveness of English specialist smoking cessation services.

DESIGN

Combination of observational cost and outcome data from English smoking cessation services to calculate cost-effectiveness ratios. Multivariate analysis of factors influencing variation in services' cost-effectiveness.

SETTING

Fifty-eight of the 92 specialist smoking cessation services in England in 2000/01.

METHODS

Services' costs were estimated using survey data which described services' configurations, staffing, interventions delivered and development. Information on services' throughput and outcomes (as biochemically validated 4-week smoking cessation rates) were obtained from routine sources. With reference to relevant literature and assumptions about relapse and background cessation rates, 4-week cessation rates were converted first to 1-year rates. One-year cessation rates were adjusted to reflect the likely permanent smoking cessation rate attributable to service intervention and finally attributable life-years gained were calculated. A wide variety of sensitivity analyses was performed to test the robustness of the average cost-effectiveness ratio, calculated by combining the cost and life-year gained estimates, for all services. With additional data on deprivation levels in services' areas, ordinary least-squares regression techniques were used to investigate variations in individual services' costs per client and cost-effectiveness ratios.

FINDINGS

Using an up-to-date estimate for health gain accrued by stopping smoking, the average cost per life gained was pound 684 (95% CI 557811), falling to pound 438 when savings in future health-care costs were counted. With the worst case assumptions, the estimate of cost-effectiveness rose to pound 2693 per life-year saved (pound 2293 including future health-care costs) and fell to pound 227 (pound 102) under the most favourable assumptions. Findings are comparable to previous published studies. The regression results suggest that different factors influence cost per client and the net cost per life-year saved, indicating that decision makers should be careful in setting performance targets for these services.

CONCLUSIONS

In 2000/01, English smoking cessation services provided cost-effective services operating well below the benchmark of pound 20,000 per quality-adjusted life-year saved (QALY) that is used by the National Institute for Clinical Excellence in the United Kingdom.

Lessons from the English smoking treatment services

This paper summarizes and discusses the key findings of the evaluation of the English smoking treatment services, which were established in 1999 as part of the English National Health Service. Within 4 years these services existed throughout the country and were working at full capacity, a total of pound 76 million having been spent on them over this period, excluding medication costs. In the fourth year almost 235,000 people attended treatment and set a quit date, and the total budget, including medications, was approximately pound 50 million. At the end of the fourth year the government allocated pound 138 million for the services for the period April 2003-March 2006. The CO-validated 4-week abstinence rate was 53%, the validated 52-week abstinence rate was 15%, and the relapse rate from 4 to 52 weeks was 75%. There was no sex difference in cessation rates at long-term follow-up. The cessation results and relapse rate from weeks 4 to 52 are consistent with results from published studies, including clinical trials. The estimated cost per life-year saved was pound 684 and the figure is even lower if the potential future health care cost savings are taken into account at pound 438 per life-year saved. This compares with the benchmark of pound 20,000 per life-year saved, which the National Institute for Clinical Excellence (NICE) is using to recommend new health care interventions in the National Health Service. The services were also succeeding in reaching disadvantaged smokers. However, there have been problems, and other health care systems considering an initiative of this kind should: set national training standards and increase training capacity before launching the services; standardize the provision of pharmaceutical treatments and make them as accessible as possible before launching the services; and give the services at least 5 years of central funding to allow them to become well established. Monitoring is extremely important but should not be so much of a burden that it detracts from developing a quality service and although cessation targets can be helpful, care needs to be taken that they are reasonable and do not promote throughput at the expense of quality.

The financial implications of coverage of smoking cessation treatment by managed care organizations

This paper presents results from a simulation of the financial impact and cost effectiveness of smoking cessation in a hypothetical managed care organization (MCO), using data from three large managed care organizations and from existing literature. With base-case assumptions and a market cost of capital, at five years, coverage of cessation services costs an MCO dollars .61 per member per month (PMPM). In a steady-state situation, net cost is dollars .41 PMPM. Both values include altered medical expenditures and MCO revenue patterns attributable to coverage-induced cessation. Quitters gain an average of 7.1 years of life, with a direct coverage cost of dollars 3,417 for each life-year saved. Coverage of cost-effective programs by MCOs should be strongly encouraged.

Evaluación económica del empleo de terapias farmacológicas para la cesación en el hábito tabáquico

INTRODUCTION

Public policies for smoking cessation are mainly based on advice from the primary care physician and group therapy. Several pharmacological treatments to reduce tobacco addiction are currently available. One of these treatments, bupropion, has remarkable efficacy (30% over 1 year) compared with nicotine replacement therapies (chewing gum 8%, patches 17% over 1 year). The objective of this study was to assess the efficiency of three smoking cessation strategies based on pharmacotherapies in Spain.

MATERIAL AND METHODS

The current situation of methods for smoking cessation in Spain includes a mixture of primary care physician advice, group therapy and willpower, combined with the use of drugs in a small proportion of individuals. This situation was compared with three scenarios in which the use of the available pharmacotherapies was increased (by up to 10%) for 1 year. A cost-effectiveness evaluation was used to calculate the cost per death prevented and per year of life saved in each scenario. The analysis used a time horizon of 20 years and was based on an adaptation of the HECOS model, sponsored by WHO-Euro, which enables comparison of distinct pharmacotherapy interventions. Epidemiological data were based on the National Health Survey (1997) and the National Institute of Statistics (1999).

RESULTS

The cost-effectiveness ratio of bupropion at 5 years was 70,939 euros per death prevented and was 37,305 euros per year of life saved. When the time horizon was increased to 20 years, these figures became net savings of 28,166 and 3,265 euros, respectively. The cost-effectiveness ratios for both nicotine gums and patches were higher than that for bupropion: 171,834 euros per death prevented at 5 years and 90,362 euros per year of life saved for patches and 513,004 euros per death prevented and 269,772 euros per year of life saved at 5 years. Furthermore, bupropion treatment for 1 year would prevent a greater number of deaths than the alternative strategies (approximately 3,000 deaths in a time horizon of 20 years) due to the decrease in the number of smokers.

CONCLUSIONS

The cost of some tobacco cessation methods, such as primary care physician advice and group therapy, is low but their efficacy is also low. New drug treatments increase costs and also achieve higher efficacy rates. When assessing interventions and their costs economic evaluation shows that in the long run greater use of bupropion generates net savings in tobacco-related health costs.

Cost-effectiveness of pharmacological interventions for smoking cessation: a literature review and a decision analytic analysis

To evaluate the relative cost-effectiveness of nicotine replacement therapy (NRT) and bupropion SR for smoking cessation, the authors reviewed published studies and developed a decision analytic model from the UK National Health Services perspective. Irrespective of the methods or assumptions involved, the results of published studies consistently indicated that NRT for smoking cessation is cost-effective. No published studies have evaluated the relative cost-effectiveness of bupropion SR for smoking cessation. The results of the decision analyses indicated that, as compared with advice or counseling alone, the incremental cost per life-years saved is about $1,441-$3,455 for NRT, $920-$2,150 for bupropion SR, and $1,282-$2,836 for NRT plus bupropion SR. The cost-effectiveness of adding NRT and bupropion SR to advice or counseling for smoking cessation is better than many other accepted health care interventions.

[The effects of implementing a smoking cessation intervention in Spain on morbidity, mortality and health care costs]

OBJECTIVE

We estimated the effect that a smoking cessation intervention in the Spanish population of smokers would have on smoking-related morbidity, mortality and health care costs.

METHODS

We adopted the model Health and Economic Consequences of Smoking sponsored by the WHO Health Organization and developed by the The Lewin Group. The smoking cessation intervention proposed includes pharmacological treatment to 35% of smokers who are trying to quit smoking and obtains a quit rate of 7.2%. The diseases studied are: lung cancer, heart disease, stroke, chronic obstructive pulmonary disease, asthma exacerbation, and low birth weight. The smoking-related cases of disease and of averted death and the reduction in health care expenditure due to the intervention were estimated.

RESULTS

Without intervention, at year 1 of the model, 2,136,094 smokers would be affected by some smoking-related disease; health care expenditure would be 4,286 million e and deaths attributable to smoking would total 26,537. The proposed intervention would prevent 2,613, 9,192, 17,415 and 23,837 cases of smoking-related disease at years 2, 5, 10 and 20 of the model, respectively. The saving in accumulated health care costs would amount to 3.5 million e at year 2 and 386 million e over 20 years. The accumulated prevented deaths are 284 at year 2 and 9,205 over 20 years. The intervention would save a total of 78,173 life-years by the end of the period considered.

CONCLUSIONS

The availability of new effective smoking cessation interventions and the increase in accessibility to such interventions may contribute significantly to reducing morbidity, mortality and health care costs associated with smoking in Spain.