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. 2004;328:1519–1527

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 1998;78:409-12.

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: >6 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

15. 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