Cost efficacy of smoking cessation interventions

1
Cost efficacy of smoking cessation interventions

• Robert West
• University College London
• Logroño, October 2006
• www.rjwest.co.uk

2
Outline

• Health benefits of cessation
• Effectiveness of cessation interventions
• Cost-effectiveness calculation

3
Benefits of smoking cessation life-expectancy

• Stopping smoking permanently increases life
  expectancy by
• 9 years if stopped around age 40 years
• 6 years if stopped around age 50 years
• 3 years if stopped around age 60 years
• For every year that smoking cessation is brought
  forward, life-expectancy increases by 3 months

Doll R et al. BMJ. 200432815191527
4
Benefits of smoking cessation morbidity

• Smokers spend more of their lives with pain, ill
  health and disability from
• Chronic Obstructive Lung Disease
• Coronary Heart Disease
• Peripheral vascular disease
• Blindness
• Deafness
• Dementia
• Stroke
• Osteoporosis

West, R (2006) British Medical Bulletin, in press
5
Benefits of smoking cessation smoking in
pregnancy

• Stopping smoking before or early in pregnancy
  reduces risk of
• Infertility
• Spontaneous abortion
• Stillbirth
• Low birth weight (with later risk of COPD and
  heart disease)
• Conduct disorder and criminality in the offspring
• Sudden infant death syndrome in the offspring

West, R (2006) British Medical Bulletin, in press
6
Benefits of smoking cessation secondary
prevention

• Smoking cessation
• normalises the rate of decline in lung function
  in patients with COPD, and reduces the rate of
  exacerbations and mortality from respiratory and
  cardiovascular diseases
• improves prognosis in patients with lung cancer

Anthonisen N, et al Ann Int Med 2005 142,
233-239 Kawahara M, et al Br J Cancer
199878409-12.
7
Effectiveness of smoking cessation interventions

• Percentage of smokers who achieve 6 months of
  continuous abstinence who would not have done so
  otherwise
• Face-to-face individual counselling 2-8
• Pro-active telephone counselling 2-4
• Group counselling/support 3-9
• NRT 5-8
• Bupropion 7-13
• Varenicline 14-22

These estimates and those in the following graphs
are approximate, based on a simple analysis
assuming no heterogeneity across studies
8
Effect of face-to-face individual support
Using only studies with 6 months continuous
abstinence and biochemical verification
9
Effect of group support
Using only studies with 12 months continuous
abstinence and biochemical verification
10
Effect of telephone counselling
Cochrane review gt6 month cessation not validated
11
Effect of tailored internet support
Not biochemically verified
12
Effect of NRT
Cochrane LI Low intensity behavioural support
HI High intensity behavioural support RTS
Reduce To Stop Combination various combinations
versus single NRT types Population NRT versus
no NRT in population samples without behavioural
support (ATTEMPT cohort study, not RCT)
13
Effect of nortriptyline, bupropion and varenicline
For bupropion and nortriptyline data from
Cochrane 6 months continuous abstinence and
biochemical verification varenicline 6 month
continuous abstinence data from JAMA 2006 blue
shading shows effect on 12 month continuous
abstinence rates of further 12w varenicline vs
placebo in smokers abstinence at 12w
14
Cost effectiveness calculations

• Approximately 50 of those who abstain for 6
  months achieve long-term cessation (8 years or
  more)
• Thus smoking cessation interventions typically
  achieve an increase of 1 to 7 permanent
  cessation on worst case estimates
• Without treatment, the average age of quitting of
  a 40 year-old smoker is 65 years
• Therefore a 40 year-old smoker who is help to
  stop will gain an average 6 years of life (9
  years minus 3 years)
• Treating 100 40 year-old smokers will yield a
  minimum of 6 to 42 years of life years
• If a treatment episode costs an average 150
  euros, this represents a cost per life year
  gained of 360 to 2500 euros undiscounted (720 to
  5000 euros discounted at 3 for 20 years)
• The UK National Institute of Clinical Excellence
  has an informal benchmark of 30,000 euros per
  quality-adjusted life year gained as threshold
  for value for money for the National Health
  Service

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Conclusions

• Current treatments to aid smoking cessation are
  highly cost-effective for reducing premature
  death
• This does not take account of prevention of pain
  and disability
• Even the least effective methods represent
  excellent value for money
• These clinical interventions are not a substitute
  for government action on price, smoke-free
  workplaces and media campaigns which will reduce
  overall smoking prevalence