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The economic impact of smoking is twofold:
the costs of tobacco use itself, and the costs of reducing its prevalence among
smokers. Beyond the face value of cigarette purchases, the costs of tobacco use
have more far-reaching health and economic implications on private individuals,
families, employers, and taxpayers. The costs of smoking have thus been
classified as direct, indirect, and intangible. The direct costs of smoking
include the cost of illness due to smoking on affected patients, and the health
care expenditure involved in the treatment of smoking-related illnesses (e.g.,
cost of drugs and administrative services). In the UK, direct costs of smoking
arise from GP consultations, prescriptions for drugs, and various costs related
to treating diseases attributable to smoking. Direct costs could also include
the resources used up by other agencies and charitable organizations. The World
Bank estimates that about 15% of the aggregate health care expenditure in
high-income countries can be attributed to smoking. In the UK, the direct costs
of smoking to the NHS have been estimated at between £2.7 billion and £5.2
billion, which is equivalent to around 5% of the total NHS budget each year. Smoking
also poses considerable indirect costs to society and the nonsmoking public, e.g.,
costs of second-hand smoking, costs to employers in the form of loss of productivity
and absenteeism of smokers owing to smoking-related illnesses. In addition,
smoking-induced fires, sickness/invalidity benefits, litter, etc. are all
negative externalities of smoking to society. The direct and indirect costs of
smoking can be measured and hence are tangible costs, whereas there are
some costs that cannot be easily quantified, such as loss of life, and the
burden of pain and suffering caused by smoking-induced illness. These
unquantifiable costs are often referred to as the intangible costs of smoking.
Just as there are costs emanating from
smoking, there are also benefits associated with reducing the incidence or
prevalence of smoking. Benefits here refer to the losses that could be avoided
by the individuals who quit smoking, such as cost savings from smoking in terms
of reduced morbidity and mortality, reductions in the costs of illness, and the
marginal risk of disease. Other benefits of reducing smoking prevalence are
longevity and improvement in the quality of life of quitters and passive
smokers, improved workplace productivity, reduced costs of cleaning up the
environment after smoking, reduction in fires caused by smoking, and the
resulting damage or destruction, as well as a healthier population, among other
benefits. There is a growing body of literature suggesting that smoking
cessation interventions, coupled with regulations and legislations, are
effective ways to reduce smoking prevalence. Furthermore, there is evidence to
suggest that smoking cessation interventions are among the most cost-effective
and economically reasonable ways of appropriating health care resources.
This study attempts to review the
existing evidence on the economic, health-related, and non-health-related
impact of reducing smoking prevalence. First, we summarize the search methods
and selection procedure used to conduct the systematic review, and then we
examine the quality assessment method used in evaluating the study quality. The
paper utilizes two main approaches used by medical researchers for economic
evaluation: cost-effectiveness analysis (CEA) and cost–benefit analysis (CBA).
These are discussed in detail in Section “Measures of Evaluating Economic
Impact”. The aim of this paper is to identify evidence on the effectiveness and
cost effectiveness of smoking cessation interventions and also to identify data
that may be of use in the economic modeling of the cost savings and net
benefits derivable from investing in smoking cessation programs in the UK. Two
specific pieces of work are presented in this review. The Section “Global
Evidence on the Economics of Smoking” examines the evidence globally on the
costs and benefits attributable to smoking, and then reviews the literature on
the effectiveness and cost effectiveness of smoking cessation programs across
countries. These will be examined under six broad headings:
1) Pharmacological treatment
interventions
2) policy-based interventions
3) Community based interventions
4) Telecoms, media, and technology
(TMT)-based interventions
5) school-based interventions
6) workplace- or employer-based
interventions.
The second major segment of this review
(“The Economic Impact of Smoking and Smoking-cessation Interventions in UK”)
examines the economic impact of smoking in the UK. The rationale for narrowing
down to UK is to assess how these various types of interventions are applied in
a single country case study. Here, the costs and benefits of smoking in the UK
are examined, as well as the effectiveness and cost effectiveness of
UK-specific smoking cessation intervention programs. The Section “Discussion”
discusses the main findings of the review by comparing results across types of
intervention, across countries, and across measurement outcomes, and in some
cases, providing the range of costs or cost savings for each intervention by
combining costs from multiple sources. The section also discusses some of the
known limitations of the study.
Search methods and selection criteria:
overview
A systematic review produced several
studies, out of which a total of 99 literature sources on the economics of
smoking and of reducing smoking prevalence were used for the review. We
captured major economic studies on the health and economic impact of smoking
and cost effectiveness of tobacco policies published between 1992 and 2014, but
included only eight relevant studies before 1992. We also performed
hand-searching of relevant articles, which produced additional 52 papers,
including useful non-economic studies, and health reports and white papers
issued by government bodies, international health organizations and health
intervention campaign agencies that are usually not included in the electronic
databases. This brings the total number of studies included in the review to
151. Of this number, 123 were strictly peer-reviewed medical journals, while 28
were useful government (public health) reports and white papers. This paper
benefits strongly from the inclusion and synthesis of high-level evidence from
mostly recent studies (eg, 2005–2014), with the implication that newer and
better methods, indicators, or measures have been reported in order to aid
economic modeling.
Study outcomes
Primary outcomes of the selected studies
are smoking prevalence, direct and indirect costs of smoking, and the costs and
benefits of smoking cessation interventions (e.g. “cost per quitter”, “cost per
quality of life year gained”, “cost per life saved”, “present value” or “net
benefits” from smoking cessation, and “cost savings” from personal health care
expenditure).
Identification of studies
Two main electronic databases were
searched. These are PUBMED (January 1992 to July 2014) and CRD (NIHS) (January
1992 to July 2014). The reason for the selection of these databases is that
they are both very comprehensive databases containing health care-related
studies. For example, PUBMED contains more than 23 million citations for
biomedical literature from MEDLINE. The CRD database also contains the NHS
Economic Evaluation Database, the Cochrane Library of Systematic Reviews in
health care and health policy, and other health care-related bibliographic
sources. To identify relevant studies for this review, we used a detailed
search strategy for each database. These were based on the search strategy
developed for PUBMED but revised appropriately for each database to take
account of differences such as vocabulary and syntax rules. Key terms used were
“economic” or “costs”, or “cost effectiveness” and “smoking”, or “tobacco” for
the international evidence section, while the search strategy for the UK
segment of the study included “UK” to the list of key words (see Supplementary
File 1). Other keywords used were “tobacco control”, “smoking reduction”,
and “smoking cessation”. We also performed hand searches on other databases
such as EconLit, Science Direct, JSTOR, Cochrane Library, and Google Scholar
using the same keywords, and this produced most of the papers already contained
in PUBMED/MEDLINE and CRD. Unpublished reports, abstracts, brief and
preliminary reports were considered for inclusion on the same basis as
published reports. There was no restriction based on language or date.
Data collection and analysis
Selection of studies: The
authors read all titles and/or abstracts resulting from the search process, and
any irrelevant studies were removed. Full copies of the remaining potentially
relevant studies were obtained and assessed independently by the authors to
ensure that these clearly met all inclusion criteria. Those that were clearly
irrelevant or had insufficient information to make a decision were excluded, or
the authors were contacted for further information to aid the decision process.
Decisions were based on inclusion criteria, ie, types of studies, types of
participants, interventions, and outcome measures used. Variations in authors’
opinion were resolved through discussion and consensus.
Under the review of international
(non-UK) evidence in Section “Global evidence on the economics of smoking”, we
assessed and summarized 36 papers on the costs and benefits of smoking as well
as 65 papers on the effectiveness and cost effectiveness of smoking cessation
interventions across countries. Though a substantial part of the evidence on
the economics of smoking were drawn from the United States, we tried as much as
possible to reflect pockets of evidence from other countries around the world,
especially from China, the largest producer and consumer of tobacco products,
as well as from Australia, Hong Kong, Korea, Thailand, Taiwan, Sweden, France,
Belgium, Denmark, India, Turkey, Netherlands, and Canada. These countries
appear to be known to have carried out comprehensive tobacco control policies.
This study reviewed only relevant papers on the effectiveness and cost
effectiveness of smoking cessation under six headings: (1) pharmacological interventions (2), policy-based
interventions (3), community-based interventions, (4), TMT-based interventions
(5), school-based interventions (6 and workplace- or employer-based
interventions.
With regard to the UK, in Section “The
economic impact of smoking and smoking cessation interventions in UK”, this
study reviewed 33 papers, 19 on the costs and benefits of smoking in UK and 14
studies on the effectiveness and cost effectiveness of UK-specific smoking
cessation interventions. Cost estimates are mostly expressed in US dollars for
international evidence (except where stated otherwise) and in British pounds
for UK evidence.
Data extraction and management
Data were extracted from published
sources using a standard data recording form. Studies that reported primary
outcomes were extracted and reviewed. At the first level of screening, we
excluded papers that merely described the effectiveness of an intervention
without including economic or cost considerations. We also excluded studies
that combined smoking cessation with the reduction in the risk of other
diseases such as lung cancer, myocardial infarction, chronic obstructive pulmonary
disease (COPD), stroke, obesity, diabetes, coronary heart disease, etc. At the
second level of screening, we excluded papers in which study design, methods,
or outcomes did not appear to be consistent with those of the review as well as
publications that appeared more than once in both databases. Figure 1 illustrates the study selection process more
clearly.
Risk of bias
The risk of bias in studies was assessed
via the criteria described in version 5.0.0 of Cochrane Reviewers Handbook.43 This
is based on the evaluation of six specific methodological domains (ie, sequence
generation, allocation concealment, blinding, incomplete outcome data,
selective outcome reporting, and other issues). Generally, the six domains are
used by answering a prespecified question about the adequacy of each study in
relation to each domain, such that a judgment of “Yes” indicates low risk of
bias, “No” indicates high risk of bias, and “Unclear” indicates unclear or
unknown risk of bias.
For this review, the following domains
were used: sequence generation, allocation concealment (avoidance of selection
bias), incomplete outcome data, and selective outcome reporting. Blinding was
not possible because of the nature of some of the studies/intervention used.
Measures of evaluating economic impact
We now discuss two methods commonly used
by medical researchers for economic evaluation: cost effective analysis (CEA)
and cost-benefit analysis (CBA).
Cost effectiveness analysis
CEA is a measure of cost savings. It
tends to link the cost of an intervention to the health improvements or gains
caused by that intervention. Measures of health improvements include cases
avoided (CA), hospital days avoided (HDA), deaths averted (DA) and life-years
saved (LYS) Other measures include cost per quitter (CPQ) enrolled in
community-based cessation programs such as a self-help program, a smoking
cessation class, an incentive-based cessation contest, or in a quit line
program. The cost effectiveness of a cessation program may not only be looked
at in absolute terms but also in relative or comparative terms to other
intervention programs because each program may have different dimensions of
cost effectiveness. Cost effectiveness is usually measured in ratios. A higher
cost effectiveness ratio means that a program is less cost effective than
another intervention program. However, Altman et al44 put
forward an argument that the fact that an intervention program yields a high
cost effectiveness ratio does not necessarily imply that it is a less desirable
outcome. It may well mean that even the most cost-effective program only
impacts on a small fraction of the population in need, so that a wiser decision
would be to implement as many cost-effective programs that satisfy the needs of
more diverse groups of citizens.
Cost–benefit analysis
CBA is an economic technique that is
used in evaluating the economic soundness or feasibility of an intervention
program. CBA measures both the costs and monetary benefits derivable from an
intervention, discounted at their present value. Discounting helps to make
divergent outcomes of costs and benefits comparable irrespective of the date at
which they occur. According to Phillips and Prowle,22 there
are three basic stages involved when conducting a CBA: (1) the costs incurred
in the intervention program must be identified, measured, and assessed; (2) the
benefits associated with the intervention also has to be identified, measured,
and assessed in which case any input–output misalignments or time-dependent
outcomes (eg, of a reduction in smoking prevalence) will have to be adjusted;
(3) the costs and adjusted benefits are now combined to arrive at a measure of
the net present value of outcomes, ie, the difference between the present value
of benefits and the present value of costs. If benefits exceed costs, then the
intervention is economically viable, and has a positive net benefit. Otherwise,
it has a negative net benefit. Another way of looking at this is to estimate
the benefit–cost ratio, that is, the present value of benefits divided by the
present value of costs. The higher the benefit–cost ratio, the more desirable
is the outcome of the intervention. It should be noted that many health
researchers find it difficult to attach monetary values to health outcomes, and
hence find the technique less useful than CEA and CUA.5
Global Evidence on the Economics of
Smoking
According to the Campaign for
Tobacco-Free Kids,46 the
top five cigarette-consuming countries are China, Russia, United States, Japan,
and Indonesia. China consumes more than 35% of the world’s cigarettes, with 53%
of males smoking. Philip Morris International, British American Tobacco, Japan
Tobacco International, and Imperial Tobacco are the world’s four largest
multinational tobacco companies. The largest state tobacco monopoly is the
China National Tobacco Corporation, which has the largest share of the global
market among all companies. Based on WHO estimates, tobacco use costs the world
an estimated $500 billion each year in health care expenditures, productivity
losses, fire damage, and other costs. In the US alone, smoking causes more than
$193 billion each year in health-related costs, including medical costs and the
cost of lost productivity caused by smoking.5,47 New
figures from the Campaign for Tobacco-Free Kids show that the social cost of
smoking in the US could be estimated at about US$321 billion (ie both
smoking-caused health costs of US$170 billion and associated productivity
losses of US$151 billion).59 (See Fig. 2). This section examines the economic costs and
benefits of smoking in some detail, citing examples from countries where
tobacco is in high demand and use.
Figure: 2
Smoking-attributable expenditure in the
United States (USD billion).
Note: Campaign for Tobacco-Free
Kids.
Smoking-attributable costs and benefits
As shown earlier, the costs of smoking
can be classified into health-related costs and non-health-related costs.
Health-related costs
The health care costs associated with
tobacco-related illnesses are extremely high. In the United States, total
annual public and private health care expenditures caused by smoking amount to
approximately US$170 billion. Measured as a proportion of the gross
domestic product (GDP), smoking costs in the US are approximately 1% of the
GDP. Many studies have estimated the health-related costs of smoking. These
costs include medical expenditure on drugs and administration,
smoking-attributable morbidity and mortality, medical costs attributable to
passive smoking, maternal smoking, and children smoking. Other direct costs
include sickness/invalidity benefits attributable to tobacco abuse. A study by
Yang et al48 reveals
three ways in which smoking-attributable expenditures could be measured—average
expenditure per inpatient hospitalization (or admission), average expenditure
per outpatient visit, and self-medication expenditures. Some other indicators
of health care expenditure include smoking-induced emergency and general practitioner
visits for adults and children, and use of nursing homes and home-based care.
Annual federal and state government
smoking-caused Medicaid payments are estimated at US$39.6 billion (federal
share: US$22.5 billion; states’ share: US$17.1 billion) (see Fig. 2). State-level estimates from USA revealed that the
direct costs of smoking in California in 1999 were US$8.6 billion, with nearly
half of this amount (47%) going to hospital care, 24% for ambulatory care, 15%
for nursing home care, 13% for prescriptions, and 1% for domestic health care
services. Fresh statistics from Campaign for Tobacco-Free Kids50 on
state tobacco-related costs and revenues has revealed that smoking-related
medical expenditures in US varied dramatically across states, with a low of
US$22.4 million in Wyoming to a high of US$3.31 billion in New York. Another
report by Armour et al51 showed
that the proportion of health care expenditure attributable to smoking ranged
between 6% and 18% across the different states.
The National Drug Strategy in Australia
estimated the total social costs of smoking in Australia between 2004 and 2005
at about AUD$31.4 billion, representing 56.2% of total costs of drug abuse in
Australia.16 Of
these costs, AUD$12.02 billion or 38.2% was classified as tangible costs, while
AUD$19.45 billion or 61.8% was intangible costs. Yang et al48 estimated
the economic burden of smoking for 2008 in China at US$28.9 billion,
representing 0.7% of China’s GDP and 3% of national health care expenditures.
This figure also averaged US$127.30 per smoker. According to the study,
mortality costs contributed the most to smoking-attributable costs in China,
followed by outpatient expenditures. Results also show that, as a result of
high prevalence rate, a whopping 93% of total economic cost of smoking in China
was borne by men. Results from Hong Kong reveal that annual health-related cost
of smoking in 1998 was US$688 million.49 The
same study shows that about 5,596 deaths in Hong Kong among adults 35 years of
age and above in 1998 was attributable to active smoking, while passive smoking
accounted for 1,324 deaths. This brings to a total of 6,920 tobacco-related
deaths out of 32,847 deaths. In what seems very surprising, passive smoking
accounted for 23% of total smoking-related health care costs in Hong Kong,
implying a growing risk of the prevalence of passive smoking. In Taiwan, the
total smoking-attributable expenditures (SAEs) totaled US$397.6 million,
representing 6.8% of the total medical expenditures for people aged 35 years and
over.52 The
mean annual medical expenditure per smoker was US$70 more than that of each
nonsmoker.
Although the health risks associated
with passive smokingd have
been well documented in the literature, little is known about the economic
costs. Regular exposure to second-hand smoke (SHS) among nonsmokers both at
home and in the workplace could be economically costly in as much as it poses
enormous health hazards. Following a recent research conducted by Plescia et al53 on
SHS exposure in North Carolina, the total annual cost of treatment for
conditions related to such exposure was estimated to be US$293.3 million in
2009. Though the majority of the SHS victims were children, the most common
cases were traceable to cardiovascular conditions. In a similar study in
Minnesota by Waters et al,54 the
total annual cost of treatment for conditions associated with SHS was estimated
to be US$228.7 million in 2008 dollars—equivalent to US$44.58 per Minnesota
resident. Just as passive smoking poses huge health care costs, smoking during
pregnancy, otherwise called “maternal smoking”, also has some related cost
implications. It is associated with considerably higher child health
expenditures as well as increase in overall medical costs.55 For
example, the annual direct medical expenditure for early childhood respiratory
illness attributable to maternal smoking totaled US$661 million for all
children under the age of six.56 Further
evidence reveals that smoking-attributable neonatal costs in the US represent
almost US$367 million in 1996 dollars.57 Though
these costs vary considerably from state to state, they can easily be avoided
by implementing temporary cessation programs aimed at pregnant women.
The foregoing statistics indicate that
smoking everywhere is very costly in many respects and takes a huge toll on
public finances. For most countries, smoking-attributable costs represent the
largest single expenditure in total health care costs, with wider implications
for the economy.
Non-health-related costs
Besides the health care costs of
smoking, there are other costs that the abuse of tobacco imposes on society,
and these costs need not be treated as less important. Tobacco-related
illnesses and premature mortality impose high productivity costs to the economy
because of sick workers and those who die prematurely during their working
years. Lost economic opportunities in highly populated developing countries are
likely to be particularly severe as tobacco use is high and growing in those
areas.58 Countries
that are net importers of tobacco leaf and tobacco products lose millions of
dollars a year in foreign exchanges. Fire damage and the related costs are
significant. In 2000, about 300,000 or 10% of all fire deaths worldwide were
caused by smoking, and the estimated total cost of fires caused by smoking was
US$27 billion.59 Tobacco
production and use also damage the environment and divert agricultural land
that could be used to grow food.
The economic loss to employers in the
form of workplace absenteeism and the resulting lost productivity of their
smoking employees is particularly alarming. In specific terms, employers suffer
loss of revenue from the days off work and earnings lost from work owing to
smoking-induced illness and premature death of its smoking employees during
productive years. It is reported that US smokers are absent from work
approximately 6.5 days more per year than nonsmokers. They make about six
visits more to the health care centers per year than their nonsmoking
counterparts, while dependents of smokers visit health care centers four times
more than nonsmokers.23,56 Recent
US statistics show that the total cost of productivity losses caused by smoking
each year amounts to US$151 billion.47,59 This
estimate only includes costs from productive work lives shortened by
smoking-caused death, and does not include costs from smoking-caused disability
during work lives, smoking-caused sick days, or smoking-caused productivity
declines when at work, all of which amount to huge economic losses to the US.
In California alone, the annual value of lost productivity owing to
smoking-related illness between 2000 and 2004 averaged US$8.54 billion (US$6.87
billion for Florida; US$6.79 billion for Texas, and US$6.05 billion for New
York), showing that these US states and many others have lost huge productive
hours and potential revenue owing to smoking-induced health problems. These
results suggest that, if adequate measures are taken by primary health
authorities and employers to promote smoking cessation, there will be huge cost
savings from smoking-related illnesses and premature deaths.
Absenteeism and premature deaths
represent only a fraction of the aggregate indirect burden of smoking to
employers. It may well be that even at work smoking-induced illness could
retard the performance of smoking employees and translate into lost time and
earnings, which may not be easily quantified. Arguing in this light, Thompson
and Forbes60 noted
that productivity losses emanating from smoking for the most part arise from
short-term absenteeism or from performance at less than full efficiency due to
respiratory problems or other smoking-induced illnesses. However, one cannot
overlook the impact of other qualitative factors that lead to absenteeism and
reduced productivity such as other health indicators (alcohol, weight,
exercise, etc), job characteristics (occupation type, income, employment
status, hours worked), and demographic characteristics (age, sex, ethnicity,
marital status, education, place of work, etc). Evidence from Bush and Wooden61 revealed
that, even after controlling for these factors, smoking was still highly
correlated with work-place absenteeism. In fact, in their 1994 paper on the
impact of smoking and alcohol on workplace absence, Bush and Wooden concluded
that, after controlling for the effect of other variables, employees on smoking
status were found to be 1.4 times more likely to be absent, and ex-smokers were
found to be 1.3 times more likely to be absent than nonsmokers. Their results
also showed that the probabilities of smoking-induced absenteeism differed
considerably by sex. For male smokers, the probability of workplace absence surpassed
that of male non-smokers by 1.7 times, while for female smokers the probability
of absence fell slightly to 1.2 times more than those females who have never
smoked.
Apart from smoking-attributable
absenteeism, cigarette smoking and its associated activities can also be
economically costly when they are the cause of fires. In the study conducted by
Collins and Lapsley,17 the
total cost of smoking-attributable fires in New South Wales, Australia, in
2006/2007 was estimated at AUD$51.4 million, with tangible costs representing
over three-quarters of the total cost. In USA, smoking-induced fires lead to
the death of 2,300 civilians (men, women, and children inclusive) per year,
with additional 5,000 injuries per year.23,56 Besides
the health care costs of treating injured or burn victims, direct property
damaged from fires induced by tobacco has been valued at US$552 million per
year. Other costs to employers of workers who smoke include health care claims
and benefits not related to health care.23 There
are also some hidden costs that are economically significant to society but
often omitted in most studies for the lack of satisfactory data, eg, costs of
paramedical and ambulance services, damage caused by smoking-induced forest
fires, toxic effects from tobacco consumption, especially amongst children, as
well as accidents and other property loss caused by cigarette smoking apart
from fires.
Economic benefits of smoking
The cost of smoking notwithstanding, the
tobacco industry poses a great deal of benefits, especially to the economy,
consumers, and producers. It is therefore imperative to examine the positive
economic effects of smoking and, hence, the impact or consequences on these of
reducing smoking prevalence. Following previous studies by Thompson and Forbes,60 Woodfield,62 and
Cohen and Barton,56 among
others, the major benefits of smoking are in economic stimulation, namely
income generated from production and consumption, tax yields, employment, and
early death of smokers. Taxes on cigarettes have always contributed to
government treasury. In 2009, President Barrack Obama signed an act that raised
the US federal tax rate on cigarettes from 39 cents to US$1.01 per pack. The
156% tax increase was estimated to earn the US government about US$33 billion
in tax over a 4½-year period. There are, however, economic consequences of
raising taxes (see “The economics of policy-based interventions” Section).
The World Bank estimates that tobacco
farming employs about 33 million people worldwide, and about 15 million of
those workers reside in China alone.63 In
China, over 4 million households rely on tobacco for their livelihood, as
tobacco farmers, cigarette industry retailers, or employees.32 In
fact, China is the largest producer and consumer of tobacco worldwide. All
cigarettes are produced by the Chinese government’s tobacco monopoly company,
which produces more than 1.7 trillion cigarettes annually. In 2003, the company
generated almost US$2 billion in profits and taxes, while income from tobacco
represented about 7.4% of centrally collected government revenue. In terms of
consumption, China boasts of a smoking population of 350 million active smokers
and 460 million passive smokers. In 2010, about 52.9% of Chinese men and 2.4%
of women were current smokers.48 Given
that China is the most populous country in the world, this proportion of smokers
translates into enormous earning potential.
Apart from the income benefits of
tobacco smoking, another source of benefit, especially to the government, of
smoking is the substantial cost savings in pension payments from premature
death of smokers. This is a highly debated issue in the literature, because it
is premised on the thinking that a shorter life expectancy implies a reduced
expenditure on pensions. Thus, attempts to promote this will be deemed socially
undesirable and hence cannot be incorporated into social policy design.60,62
Clearly, from the above, therefore, if
tobacco farming is to be phased out, many households, investors, and the
government itself will suffer huge economic losses. Hence there is a need to
strike a balance between the costs and benefits of smoking. But this is easier
said than done, especially as the health implications of smoking far outweigh
any associated economic returns from the perspective of a socially desirable
outcome.
Effectiveness and cost effectiveness of
smoking cessation interventions
Because the health hazards attributable
to smoking are very significant, the risks of illness or disease are reduced
following smoking-cessation interventions.19 According
to a UK General Household Survey in 1998, about 27% of adults (aged 16 years
and above) were smokers, and of this figure about 70% wanted to quit smoking.
Data from a similar survey conducted in 1994 by the US health authorities
indicated that 46.4% of smokers had made serious attempts to stop in the year
preceding the survey, but only 5.7% of smokers managed to abstain from smoking
after a period of 1 month or more, and only 2.5% of smokers are able to achieve
permanent abstinence each year. The reason for this is smoking is an addiction
and can hardly be stopped on the basis of will power alone. Evidence from
Feenstra et al11 shows
that only ~3%–7% of smokers who attempt to stop smoking on will power are still
abstinent after 1 year. In order to enhance quit rates, there must be some
deliberate measures to incentivize cessation. There are different forms of
smoking cessation interventions, and they range from pharmacological treatment
interventions to policy-based interventions, community-based cessation
programs, TMT-based interventions, school-based interventions, and workplace-
or employer-based interventions.
The aim of this section is to identify
and evaluate cross-country evidence on the effectiveness and cost effectiveness
of smoking cessation interventions. The idea of carrying out economic
evaluations is to identify which interventions utilize the least resources or
have greater cost savings, while being most effective in reducing both the
number of smokers and the health- and non-health-related risks associated with
smoking. By comparing the costs and outcomes of different alternative
interventions, economic evaluations help health care professionals and policy
makers in deciding the most efficient use of scarce resources.24 In
estimating the effectiveness of cessation interventions, two major indicators
are necessary: the number of long-term quitters and the health gains from
smoking cessation, measured according to the age and sex of the quitters.19 In
estimating the cost effectiveness of smoking cessation interventions, emphasis
is placed on the impact of such interventions on direct cost reductions with
respect to smoking-related morbidity and mortality rates as well as the effect
on long-term medical expenditure.
Pharmacological treatment interventions
There are several pharmacological agents
that are commonly used to aid smokers in their quest to quit smoking. However,
we will concentrate on the three major types: nicotine replacement therapy
(NRT), bupropion sustained release (SR), and varenicline. These treatment
interventions are widely available on prescription, and in the case of NRT as
an over-the-counter medication. They are licensed as first-line treatments for
use as smoking-cessation aids in the US and the EU, and are widely recommended
in many national guidelines.64
The aim of NRT is to temporarily replace
much of the nicotine from cigarettes to reduce motivation to smoke and the
physiological and psychological withdrawal symptoms often experienced during a
quit attempt, thus easing the transition from cigarette smoking to complete
abstinence. It is available in various forms and dosages, including transdermal
patches (ie, absorbed slowly through the skin), as chewing gum, oral and nasal
sprays, lozenges, sublingual tablets, and inhalers. NRT, in all its
commercially available forms, has been found to help people who make a quit
attempt to increase their chances of successfully stopping smoking. NRT increase
the rate of quitting by as much as 50%–70% regardless of setting.65
Bupropion was developed as a
non-tricyclic antidepressant, and is sometimes preferred by smokers who do not
wish to use a nicotine-based treatment, or who have already failed to quit
using NRT. The usual dose for smoking cessation is 150 mg once a day for 3
days, increasing to 150 mg twice a day, continued for 7–12 weeks.64 The
quit attempt is generally initiated a week after starting pharmacotherapy. Some
studies have shown that bupropion doses up to 300 mg per day does have
significant effect in a dose–response fashion on smoking cessation, but does
not seem to affect long-term cessation rates (see66).
Varenicline is a selective nicotinic
receptor partial agonist, licensed as a prescription-only treatment for smoking
cessation in USA in 2006 and in Europe in 2006/2007. The standard regimen is 1
mg twice a day for 12 weeks, with the first week titrated to reduce side
effects, and quit date set for the second week. Varenicline has helped ~50%
more people to quit than nicotine patch and “other” NRT (tablets, sprays,
lozenges, and inhalers) and ~70% more people than nicotine gum.64 This
means that for every 10 people who quit with NRT patch or with “other” NRT,
about 15 could be expected to quit with varenicline, and for every 10 who quit
with NRT gum, about 17 could be expected to quit with varenicline.
NRT, bupropion, and varenicline all
improve the chances of quitting, with low risk of harms, and in some cases,
using a combination of these pharmacological treatments could be seen to be
even more clinically effective. However, as noted earlier, to justify the
investment in any intervention, its effectiveness must be evaluated alongside
its cost effectiveness. The cost effectiveness of pharmacological interventions
is thus as important as their clinical effectiveness. A review of economic
studies on these pharmacological treatment interventions (see Supplementary
File 2) showed that varenicline and bupropion (with or without behavioral
interventions) are more cost effective than NRT measures such as nicotine gum,
patch, lozenge, and inhaler. A recent study by the Canadian Agency for Drugs
and Technologies33 found
that, if providers’ willingness to pay (WTP) was greater than US$10,000 per
QALY gained, then varenicline was the optimal treatment of choice compared to
NRT and bupropion.
Several studies have also found that the
use of NRT and/or bupropion SR along with GP counseling is both clinical and
cost effective in primary health care. For example, Stapleton et al67 showed
that contingent prescriptions could yield additional life years at a cost between
£398 (US$724) and £758 (US$1,380) in 1998 UK pounds compared to brief
counseling alone. In a similar estimation of the cost effectiveness of treating
nicotine dependence (including NRT and counseling), Croghan et al68 found
the aggregate 1-year smoking rate to be 22% with a cost of $9,231 per net life
year gained. This cost compares favorably with other medical services that rely
only on GP counseling however brief or intensive. Although NRT products can be
purchased over the counter, many people have suggested that free NRT treatments
yield more positive results in terms of number of quitters than other cessation
interventions. For example, Ong and Glantz69 found
that in Minnesota, a free NRT program would generate 18,500 quitters at a cost
of US$4,440 per quality of life adjusted years (QALY) compared to implementing
a smoke-free workplace policy, which would generate 10,400 quitters at US$506
per QALY.
Nielsen and Fiore70 conducted
a CBA of bupropion SR and nicotine transdermal patch (NTP) to see which of the
two, or whether a combination of both, was more cost effective for smoking
cessation. The results revealed that bupropion is more cost beneficial than
either NTP or bupropion and NTP together, producing a net benefit in the first
post-quit year of up to £338 per employee who attempts to quit compared with US
$26 for NTP only, US$178 for the two combined, and US$258 for placebo, another
pharmaceutical therapeutic that was used in the clinical trials. Thus,
according to this study, bupropion is able to offer the most substantial
monetary benefits than any other pharmacological treatment. In a more recent
study by Bolin et al,31 the
cost effectiveness of varenicline was compared with nicotine patches for
smoking cessation in four European countries (Belgium, France, Sweden, and UK).
Surprisingly, the results showed that the use of varenicline for smoking
cessation was associated with reduced smoking-related morbidity and mortality
more than was the case using NRT. The number of morbidities avoided per 1,000
smokers who made attempts to quit ranged from 9.7 in Belgium to 6.5 in UK. The
number of QALY gained, per 1000 smokers, was 23 in Belgium, 19.5 in France,
29.9 in Sweden, and 23.7 in UK. The results of the base-case simulations
revealed that, with the exception of France, varenicline treatment appeared to
be more cost effective and cost saving than NRT. Thus, funding varenicline as a
smoking cessation aid is an economically justifiable use of health care
resources in these countries.
The economics of policy-based
interventions
This subsection takes a look at the
global evidence on the economic consequences of policy-based measures that aid
smoking cessation. These include price-based measures (eg, increase in tobacco
taxes, limitations on tobacco crop subsidies) and non-price measures (eg, no
smoking regulations at work and in public places, restriction on sales to
minors, and bans on promotion and advertising, etc). Legislative bans could
either ban smoking completely (comprehensive) or restrict it to designated
areas (partial). Both price-based measures and legislation-based smoking bans
or restrictions have been found to yield both health and economic gains,
including (1) reduction in smoking prevalence though reductions in the demand
for and consumption of cigarettes, (2) significant reductions in the incidence
of smoking-related diseases and deaths, (3) reduction in smoking-related medical
costs, and (4) large gains in cumulative life years and QALYs.23,36,37,71–79
Increase in tobacco taxes
The most widely used measure to reduce
the demand for tobacco is increase in taxes. This puts an upward pressure on
tobacco prices, and higher tobacco prices tend to significantly reduce the
consumption of tobacco.74,77 According
to a World Bank report,63 when
taxes are raised on tobacco, consumption decreases especially in young people;
a 10% cigarette price increase results in a 7% decrease in smoking by young people
and 4% by the general public. It has also been hypothesized that a price
increase of 10% would reduce smoking by 4% in high-income countries and by
about 8% in low-and middle-income countries.23,71 In
other words, the price elasticity of demand for tobacco is higher in low- and
middle-income countries and among populations of young or teenage smokers who
are the most responsive to price changes. Smokers in high-income countries are,
however, less responsive to price changes. According to Atkinson and Townsend,80 low
price sensitivity means that the revenue argument against tax increases is
rather unconvincing. As long as prices do not respond proportionately to tax
increases (ie, price elasticity of less than 1), the revenue from tobacco will
surely increase when taxes go up since “a fall in consumption is more than
offset by the extra tax paid by those who continue to smoke” (pp. 492). Thus,
according to Atkinson and Townsend, so long as the reduction in tobacco
consumption is attributable to increased duty, the amount of corporate revenue
from tobacco is likely to remain unaffected. The World Bank has recommended
that “Governments increase tobacco tax to about 65% of retail price”.63 Increasing
tobacco prices also increases the chances of cigarette theft, smuggling, and
counterfeiting. The Mackinac Center on Public Policy estimates that profits
made illegally from smuggling cigarettes to the US could amount to be between
US$10 billion and US$17 billion.81 Over
the years, tobacco tax increases have brought about increases in revenue for
the government, even when the incidence of smuggling and tax evasion are
discounted. Currently, in most high-income countries where tobacco control
policies are very comprehensive, tobacco taxes represent between two-thirds and
four-fifths of the retail price of cigarettes, whereas in low- and
middle-income countries, they are generally below 50% of the total price.
Apart from the decline in tobacco
consumption via increased prices, raising cigarette taxes also poses some
potential health and cost-saving benefits. Reduced tobacco consumption leads to
a reduction in health care costs as former smokers and their children do not
require as much medical care or treatment as they used to.23 There
is also another argument that says that huge tobacco taxes are equitable in the
sense that it makes the tobacco industry pay more for the huge economic burden
placed by its products to the health care system as well as the negative externalities
of same to society. The income generated from tobacco taxes can also be used to
finance community education and advertising against tobacco. In China, the
largest producer and consumer of tobacco, a recent tobacco tax adjustment has
just been implemented and, if this tax increase passes through to retail
prices, it is expected to reduce the number of smokers by 630,000 saving
210,000 lives, at a price elasticity of −0.15.32 Following
the same model, a tax increase of 1RMB (or US$0.13) per pack of cigarettes is
expected to increase the revenue accruable to the Chinese government by 129
billion RMB (US$17.2 billion), reduce consumption by 3.0 billion packs of
cigarettes, reduce the number of smokers by 3.42 million, and save 1.14 million
lives. These figures indicate that tobacco tax increase in China can be
construed as the most cost-effective measure of smoking cessation.
In summary, tobacco tax increases reduces
tobacco consumption via higher cigarette prices, raises government revenue,
saves more lives, preserves employment, and reduces tobacco farming. However,
whether or not tax increases lead to loss of revenue in the tobacco industry is
still a subject of debate, as smuggling and tax evasion help to minimize any
losses arising from taxation.
Smoking restrictions in the work place
and in public places
It is in recognition of the dangers of
passive smoking that many governments institute no smoking restrictions in
public places (eg, bars, restaurants, public buses, trains, airports,
government buildings, and other public facilities) and private workplaces.
Governments are now increasingly sensitive to the need to protect its citizens
from the externalities caused by environmental tobacco smoke. Evidence from the
US and Canada suggests that smoke-free air policies are associated with a
significant reduction in cigarette consumption.23,71,82 In
a report issued by the United States Environmental Protection Agency, the costs
and benefits of a proposed national smoke-free environment act were modeled to
identify its net benefits. The proposed policy was meant to curtail
significantly smoking in public places entered by more than 10 people per week.
The costs considered were costs of implementing and enforcing the restriction,
costs of building and maintaining smoking lounges, among other costs. The
benefits included savings from smoking-related medical expenditures, heart
diseases averted, the value of lives saved, costs averted by a reduction in
smoking-induced fires, and gains in productivity.83 The
net present value to society was estimated to fall between US$42 and US$78
billion, and this range was obtained by considering high and low estimates of
costs and benefits. In another study by the Stephens et al,82 they
analyzed the relationship between cigarette prices and no-smoking bylaws to the
prevalence of smoking in Canada. Results from a comparison of price and policy
differences among Canadian provinces showed that the tendency of being a smoker
falls with rising cigarette prices and with widespread no-smoking regulations,
even after controlling for age, sex, education, and marital status of
respondents. They thus concluded that no smoking regulations should be
accompanied by an increase in cigarette prices to be more effective. If either
were used in isolation, the outcomes will likely produce a lesser impact than
the two measures used together.
Bans on tobacco advertisement
Tobacco remains the second most heavily
advertised product in the United States besides the automobile industry.23 Over
the years, it has been widely advocated that bans be placed totally on
cigarette advertisements and promotional activities. In many countries, this
bill has been a subject of controversy or debate. There are those who argue
that a partial ban on advertisement has little or no effect on cigarette
consumption.71,80 This
is because, most adverts, particularly the tobacco-industry-related ones only
reveal the brands smoked instead of the quantity smoked. In this sense,
therefore, it is difficult to measure the impact of increased or reduced
advertising on tobacco consumption. In addition, companies affected by such
legislation could seek to utilize alternative forms of media. In an econometric
study on high-income countries, Saffer and Chaloupka84 noted
that comprehensive bans on tobacco advertising tend to reduce consumption.
Community-based intervention programs
Smoking cessation programs also come in
the form of community-based interventions to educate, inform, and assist
smokers in their quitting attempts. According to Secker-Walker et al,85 a
community intervention is defined as “a co-ordinated, multi-dimensional
programme aimed at changing adult smoking behaviour, involving several segments
of the community and conducted in a defined geographical area, such as a town,
city, country, or other administrative district” (pp. 3). These programs could
range from community pharmacy-based interventions to group-based counseling,
incentive-based smoking cessation contests, use of self-help quit smoking kit,
and, in some cases, mass media campaigns directed at certain communities within
a defined geographical area. The aim of this section is to identify and assess
global evidence on the effectiveness and cost effectiveness of such
interventions.
Nine studies on community-based
interventions were reviewed, including studies by Altman et al,44 Secker-Walker
et al,86 Stephens
et al,82 Secker-Walker
et al,87,88 Lightwood
et al,89 Hurley
and Matthews,26,30 and
Simpson and Nonnemaker.90 Altman
et al, as far back as 1987, studied the cost effectiveness and cost
distribution of three community-based smoking cessation programs designed for
use in the two education communities of the Stanford Five City Project. These
programs included (1) smoking cessation class (eight 1-hour training sessions
offered to ~8–25 participants where several quitting techniques were taught);
(2) incentive-based smoking cessation contest (a 6-week community smoking
cessation prize contest where entrants were assessed and rewarded on the basis
of their smoking status and habits); and (3) self-help quit smoking kit
(included tips on smoking replacement habits, social support available, public
commitment, and record keeping and goal setting, among other tips aimed at
providing specific actions to aid individual smoking cessation). Results
revealed that the self-help quit had the lowest total cost (US$26,190), lowest
quit rate (21%), lowest time requirement for participants, and was the most
cost effective (with a CER of $50). However, the smoking cessation class was
the most effective, requiring the most time from participants, with a quit rate
of 35%, but incurring the highest total costs (US$261,589) and was also least
cost effective (US$276). The smoking cessation contest was in-between the other
two programs, with a total cost of US$82,925, a quit rate of 22%, and a CER of
US$151.
A community pharmacy also provides an
excellent setting in which to provide a smoking cessation program, as the
pharmacy would have regular contact with residents of the area. Thavorn and
Chaiyakunapruk30 evaluated
the incremental cost effectiveness of a community-pharmacist-based smoking
cessation (CPSC) in Thailand. They found that the CPSC program yielded cost
savings and life year gains to the health system. A series of sensitivity
analyses, however, demonstrated that both cost savings and life year gains were
sensitive to variations in discount rate and long-term smoking quit rate
associated with the intervention (see Supplementary
File 2 for more details on the results).
Lightwood et al89 also
examined the effect of California’s Tobacco Control Program (CTCP) on aggregate
personal health expenditures in the state. The CTCP, which was established in
1989, offered a comprehensive approach to smoking cessation by altering the
existing social norms and values among tobacco users. The campaign featured an
aggressive media campaign with three themes, namely the tobacco industry lies,
nicotine is addictive, and second-hand smoke kills. It also included a radical
public policy change, especially in the area of promoting smoke free
environments. The findings of the study revealed that, between 1989 and 2004,
the California program led to a reduction in personal health care expenditures
to the tune of US$86 billion (in 2004 dollars), which would have been expected
without the program. Using 95% confidence interval, the cost savings ranged
between $28 billion and US$151 billion.
Hurley and Matthews26 also
presented evidence on the cost effectiveness of Australia’s National Tobacco
Campaign (NTC), an intensive mass media antismoking campaign, which was
launched in 1997. Using a quit benefits model (QBM), the study predicted that
the NTC avoided more than 32,000 cases of COPD, 11,000 cases of acute
myocardial infarction, 10,000 cases of lung cancer, and 2,500 cases of stroke.
The model also predicted the prevention of about 55,000 deaths, 323,000
life-years gain, and 407,000 QALYs, as well as a health care cost savings of
AUD$740.6 million. Thus, the NTC was both effective and cost saving.
The above studies as well as other
community-based interventions all reveal that a strong and aggressive tobacco
control program do not only reduce the number of smokers and its resulting
health benefits but also reduce substantially the health care expenditure
associated with smoking prevalence. It is worth noting that the benefits of
these initiatives may not have been well established quantitatively in the
sense that most of these studies reflect potential uncertainty in the estimates
and data used as well as differences in the parameters estimated. In some
cases, data sufficient to establish definite causality are also lacking.
However, on the balance, the community-based cessation initiatives examined
appear to yield substantial net benefits.
Telecoms, media, and technology-based
interventions
TMT-based interventions refer to
electronic and mass media-related means aimed at offering support to effect
changes in smoking behavior in adults and young adolescents. Examples include
telephone counseling offered through “quitlines” or “helplines”; radio, TV, and
print media; and computer and Internet-based intervention programs. A summary
of the results of related TMT-based cost effectiveness studies can be found
in Supplementary
File 2.
Telephone counselling, quit lines and
text messaging
Telephone services can provide
information and support for smokers. Counseling may be provided proactively or
offered reactively to callers to smoking cessation helplines.91 Support
can be given in individual counseling sessions or in a group therapy where
clients can share problems and derive support from one another. Counseling may
be helpful in planning a quit attempt and could assist in preventing relapse
during the initial period of abstinence. Although intensive face-to-face
intervention increases quit rates, there are difficulties in delivering it to
large numbers. Telephone counseling may be a way of providing individual
counseling more affordably.
Tomson et al45 examined
the cost effectiveness of the Swedish quitline, a free-of-charge service
offered to the smoking population in Sweden to aid cessation. About 31% of the
study population (354 callers) reported abstinence after 1 year of the
implementation of the scheme, leading to an accumulated number of life year
saved of 2,400. The cost per quitter ranged between US$311 and US$401. In
comparison with other smoking cessation interventions, the study concluded that
the Swedish quitline was cost effective. A more recent study by Rasmussen40 assessed
the cost effectiveness of the Danish smoking cessation telephone service
“quitline”. The study was based on the number of quitline callers in 2005. A
total 511 ex-smokers were estimated to have gained 2172 life years based on prolonged
abstinence over 12 months. Discounting life years (LYs) at 3% per annum, the
costs per LYS are €213 for ex-smokers with continued abstinence and €137 for
ex-smokers with point prevalence abstinence. The sensitivity analysis for a
worst case scenario indicates that the costs per LYS are €1199. The author
concluded that the Danish reactive telephone counseling to aid smoking
cessation appears to be cost effective in comparison with other Danish smoking
cessation interventions.
Farrelly et al92 took
a rather different dimension to the study of quitlines by assessing the
relative effectiveness and cost effectiveness of television, radio, and print
advertisements in generating calls to the New York smokers’ quitline. The
results showed that there was a positive and statistically significant
association between the call volume and expenditures for television (P <
0.01) and radio (P < 0.001) advertisements and a slightly significant
effect for expenditures on newspaper advertisement (P < 0.065). Though
television advertising had the largest effect on call volume, differences in
advertising costs for different media implied that call volume on the quit-line
was least responsive to increases in expenditure on television advertising
(0.1%) per US$1000 increase compared to the other mass media: radio (5.7%) and
newspaper (2.8%). While it was difficult to determine the optimal mix of
expenditures, the bottom line is that all three mass media effectively raised
the number of callers to the New York quitline.
Another telecom-based intervention
measure is the use of mobile phone text messaging facilities to aid smoking
cessation. A study by Guerriero et al93 used
a cohort simulation model to determine the cost effectiveness of smoking
cessation support delivered by mobile phone text messaging in the UK, called
“Txt2stop”. The cost effectiveness was measured in terms of cost per quitter,
cost per life year gained, and cost per QALY gained. The cost of text-based
support per 1,000 enrolled smokers was £16,120, which, given an estimated 58
additional quitters at 6 months, equates to £278 per quitter. However, when the
future NHS costs saved (as a result of reduced smoking) are included,
text-based support would be cost saving. It is estimated that 18 LYs are gained
per 1,000 smokers (0.3 LYs per quitter) receiving text-based support, and 29
QALYs are gained (0.5 QALYs per quitter). The deterministic sensitivity
analysis indicated that changes in individual model parameters did not alter
the conclusion that this is a cost-effective intervention. Similarly, the
probabilistic sensitivity analysis indicated a >90% chance that the
intervention will be cost saving.
Mass-media-led interventions
Mass media interventions consist of the
dissemination through television, radio, print media, and billboards of
cessation-related messages, informing smokers and motivating them to quit. Mass
media campaigns can be effective in keeping tobacco control on the social and
political agenda, in reinforcing community action, and in triggering other
interventions. Campaigns are designed either directly to change individuals’
smoking behavior (the risk factor model) or to catalyze other forces of social
change (the social diffusion model), which may then lead to change in the
social norms about smoking.94 Social
diffusion campaigns, such as those run in Australia, Canada, UK, Thailand, and
in some US states, are designed to de-normalize smoking, thus counteracting the
tobacco industry’s message that smoking is desirable and harmless.
While many studies have revealed that
mass media interventions are effective in reducing smoking prevalence among
adults, not many studies have commented on the cost effectiveness of such
campaigns. Villanti et al95 evaluated
the cost effectiveness of the American Legacy Foundation’s national “EX”
campaign, which ran on radio and TV in 2008 and was designed to promote smoking
cessation among adult smokers. The incremental societal cost of EX, in 2009
dollars, was US$166 million. Data from eight designated media market areas
studied indicate that, in a hypothetical nationwide cohort of 2,012,000 adult
smokers ages 18–49, EX resulted in 52,979 additional quit attempts and 4,238
additional quits and saved 4,450 QALYs. Incremental cost-utility estimates
comparing EX to the status quo—that is, the situation that would have existed
in eight markets with no campaign and no change in cessation behavior—ranged
from a cost of US$37,355 to US$81,301 per QALY, which suggests that the
campaign was cost effective. These findings are consistent with previous
evidence that national mass media campaigns for smoking cessation in the US can
lower smoking prevalence in a cost-effective manner. However, in a study on the
cost effectiveness of online, radio, and print tobacco control advertisements
targeting 25–39-year-old males in Australia, Clayforth et al42 found
that online advertising could be more cost effective than other non-television
advertising media such as radio and press in reaching and affecting target
audiences, implying that online campaigns may be a highly cost-effective channel
for low-budget tobacco control media campaigns (see Supplementary
File 2 for details).
Computer- and internet-based programs
Personal computers, the Internet, and
other electronic aids, which are now an indispensable part of daily life for
many people around the world, also offer additional means of effecting changes
to smoking behavior. These electronic-based measures have been found to be
effective and cost effective in reducing smoking prevalence among adults (see35,96,97).
For example, computer-tailored programs that entail the adaption of the content
of an intervention to participants’ individual characteristics using computer
programs have been found to be both effective and economically efficient.41 Most
often, a questionnaire is used as a screening instrument, in which case answers
provided by the smokers on the questions are accumulated into a large data file
and are subsequently matched with relevant feedback messages that are
ultimately combined into a tailored feedback letter. Tailored interventions are
more effective in attracting and keeping a smoker’s attention, resulting in
better processing of information. Civljak et al97 found
that Internet programs that were interactive and tailored to individual
responses led to higher quit rates than usual care or written self-help at 6
months or longer. There are two types of computer-tailored programs: single
computer-tailored programs and multiple computer-tailored programs. A
single-tailored feedback message is successful in increasing cessation rates,
but dynamically tailored feedback provided on multiple occasions can even be
more effective. Due to the automatic generation of the tailored feedback and
the fact that computer-tailored interventions are increasingly delivered
online, the integration of an internet-based computer-tailored program in the
general practice setting might limit the burden on health professionals and
patients, reduce facility and administrative costs, and could potentially be
time and cost saving.41 However,
the Internet may offer additional benefits when combined with usual
pharmacological interventions, such as NRT, varenicline, or other
pharmacotherapy.
School-based interventions
Though the majority of smoking-related
deaths occur in people aged 35 years or older, the onset of tobacco use occurs
primarily in early adolescence, which makes adolescents a special target for
smoking prevention projects. Schools have been identified as an ideal site to
deliver tobacco prevention programs since they capture the majority of youth
across a large age range, including the ages when most young people initiate
smoking. The main perceived advantages of school-based intervention programs
are that almost all children can be reached through schools, and a focus on
education fits naturally with the daily activities of schools.98 Researchers
often employ five types of school-based intervention programs, each based on a
different theoretical orientation: (1) information-only curricula, ie,
interventions that provide information to oppose tobacco use (also called
normative education). These educational programs provide content and activities
that seek to correct inaccurate perceptions regarding high prevalence of
tobacco use; (2) social competence curricula, a group of interventions that aim
to help adolescents refuse offers to smoke by improving their general social
competence—including training on life skills such as self-control, self-esteem,
decision making, and cognitive skills for resisting interpersonal and media
influences; (3) social influence curricula, educational programs that seek to
inform youths about the effects of outside influences such as advertising on
their behavior, teach them that smoking is not the norm, and give them the
skills to refuse cigarettes; (4) combined social competence and social
influences curricula, methods that draw on both social competence and social
influence approaches, and (5) multimodal programs, which combine curricular
approaches with wider initiatives within and beyond the school, including
programs for parents, schools, communities, and initiatives to change school
policies about tobacco, or state policies about the taxation, sale,
availability, and use of tobacco.
Although numerous school-based smoking
prevention trials have found short-term decreases in smoking prevalence by up
to 30%–70%, there is little or no evidence on the long-term effectiveness of
school-based smoking prevention programs.98–100 Tengs
et al101 have
reported that the effectiveness of anti-tobacco education programs using the
“social influences” model tends to dissipate in 1–4 years, raising questions
about the long-term economic efficiency of such initiatives. Using a
system-dynamics computer simulation model based on secondary data, the authors
evaluated the cost effectiveness of an enhanced nationwide school-based
anti-tobacco education and found that over 50 years, cost effectiveness is
estimated to lie between US$4,900 and US$340,000 per QALY, depending on the
degree and longevity of program effectiveness. Assuming a 30% effectiveness
that dissipates in 4 years, cost effectiveness is US$20,000/QALY. A similar
study on the cost effectiveness of a school-based tobacco use prevention
program in the US, known as Toward No Tobacco Use (TNT), showed that the
program was highly effective as the government could expect to save US$13,316
per LY saved and a saving of US8,482 per QALY saved. However, a peer-led
intervention, known as ASSIST, aimed at reduced smoking among adolescents in
England and Wales, was only valued to yield a modest cost saving, with an
incremental cost per student not smoking after 2 years of follow-up at £1,500
(CI = £669–£9,947). Other cost-effectiveness studies on school-based smoking
cessation programs are summarized in Supplementary
File 2. From all of these studies, an issue that remains unresolved is the
extent to which reductions in adolescent smoking lead to lower smoking
prevalence and/or earlier smoking cessation in adulthood.
Workplace interventions
There has been growing interest within
the business community regarding interventions against smoking in the
workplace. Smoking interventions in the workplace particularly have numerous
advantages. First, a large number of people can be contacted, canvassed, and
enrolled in programs with relative ease, sometimes with the aid of extensive
onsite occupational health facilities.102 Second,
worksites have the potential for higher participation rate than non-workplace
environments. Third, worksites have the potential to provide sustained peer
group support and positive peer pressure for quitting and staying tobacco-free.
Fourth, it provides a particular opportunity to target young men, who
traditionally have low general practitioner consultation rates and are thus
less likely to benefit from opportunistic health promotion activity in primary
care. Fifth, in some workplaces, occupational health staff may be on hand to
give professional support. Finally, the employee need not travel to attend
cessation programs; hence the workplace provides convenience benefits to the
employee.103,104 It
is worthy of note that many of these assumptions are based on a model of
workplace that is rapidly changing. With many generation-Y employees who change
jobs frequently or work from multiple locations, the net benefits from
workplace cessations could be expected to become marginal in the long run.
Workplace smoking interventions can take
numerous forms, including pharmacological interventions, behavioral
interventions, or a combination of both. It could target individuals or
specific employee groups. The main strategies include smoking prohibition,
incentives, competitions, individual and group counseling, self-help materials,
pharmacological therapy, and social and environmental support.
Many health economics researchers have
found empirical evidence to support the general belief that smoking
intervention programs help a firm’s bottom line by reducing health care costs,
absenteeism, and its attendant productivity losses and other employer-related
costs.105 However,
there are serious challenges to the reliability and validity of their findings,
as some critics of this literature have cited systematic biases affecting the
credibility of some of these studies. These biases often manifest themselves in
underestimation of costs and overestimation of benefits. Other researchers who
have carried out behavioral workplace interventions have found a strong
consistency in the correlation between smoking interventions and reduced
cigarette consumption and decreased exposure to environmental tobacco smoke.106 Smedslund
et al103 also
compared the cost effectiveness of behavioral workplace interventions compared
to pharmacological interventions and found that controlled smoking cessation
trials at the worksite showed initial effectiveness, but the effect seemed to
decrease over time and was not present beyond 12 months. Jackson et al,107 however,
showed that pharmacological interventions at the workplace seemed to generate
12-month employer cost savings per nonsmoking employee of between $150 and
$540. The authors however found that varenicline was more cost beneficial than
placebo because it had higher quit rates. Warner et al105 also
found that smoking cessation is a very sound economic investment for the firm,
and is particularly profitable when long-term benefits are included, with an
eventual benefit–cost ratio of 8.75. Other studies by Ong and Glantz108 also
showed that the first year effect of making all workplaces in the US smoke-free
would produce about 1.3 million new quitters and prevent over 950 million
cigarette packs from being smoked annually, worth about US$2.3 billion in
pretax sales to the tobacco industry. In addition to preventing the risk of
smoking-induced diseases such as myocardial infarctions and strokes, smoke-free
work places could result in nearly US$49 million in savings in direct medical
costs after 1 year. At steady state, more than US$224 million would be saved in
direct medical costs annually (see Supplementary
File 2 for summary of results).
Overall, this section has examined
evidence across countries on the economic impact of smoking and the
effectiveness and cost effectiveness of reducing smoking prevalence through
intervention programs. It has examined the health-and non-health-related costs
and benefits of smoking as well as the effectiveness and cost effectiveness of
pharmacological, policy-based, community-based, TMT-based, school-based and
workplace- or employer-based smoking cessation interventions carried out
through the years by different countries or state public health agencies. Key
statistics and examples were drawn from United States, China, Australia,
Canada, Hong Kong, Belgium, Taiwan, India, France, and Sweden. Next, this study
narrows down by reviewing the economics of smoking in United Kingdom.
The Economic Impact of Smoking and
Smoking Cessation Interventions in UK
The costs and benefits of smoking in UK
Smoking has also been responsible for
over 100,000 deaths per annum over the last decade in UK. The number of deaths
attributable to smoking in 2005 was estimated at 109,164.8 The
financial and health burden of smoking in UK is enormous. Previous studies have
estimated the direct costs of treating smoking-related diseases by the NHS to
range somewhere between £1.4 and £1.7 billion every year.10,56,109,110 A
more recent study conducted by Callum et al12 showed
that smoking-attributable costs to the NHS in 2006 was estimated at £2.7
billion. This includes smoking attributable hospital admissions (£1 billion),
outpatient attendances (£190 million), general practitioner (GP) consultations
(£530 million), practice nurse consultations (£50 million), and GP
prescriptions (£900 million). Allender et al8 estimates
the costs of smoking-induced ill health to the NHS to be £5.2 billion in
2005–2006, representing about 5.5% of the total NHS budget that yeare (see
also7).
The cost of smoking in UK is thus increasing every year. The estimates provided
by the above studies, however, are conservative cost estimates because they do
not include the indirect costs of passive smoking and productivity losses due
to smoking-related morbidity and premature mortality. The costs of informal
care, smoking-related fires, cleaning costs, and sickness absence payments were
also excluded from these estimates.
Cohen and Barton56 show
that approximately 50 million working daysf are
lost in UK annually due to smoking, valued at £1.71 billion. The British Medical
Association112 estimates
that each year in UK, at least 1,000 deaths are attributable to passive smoking
and more than 17,000 children under the age of five are admitted to hospital
because of the ill effects of second-hand smoke. Parrott and Godfrey10 have
estimated that each year in UK the cost of treating childhood illnesses related
to smoking is about £410 million. The same study estimates the damage caused by
smoking-related fires to be around £151 million each year in England and Wales.
If all these indirect costs estimates are included to the NHS figures, the
financial burden of smoking in UK will skyrocket. A more recent report by the
Policy Exchange in 2010 attempts to sum up the total estimated costs to society
of smoking in UK and puts the figure at £13.74 billion. This includes £2.7
billion cost to the NHS but also the loss in productivity from smoking breaks
(£2.9 billion), and increased absenteeism (£2.5 billion). Other costs include
cleaning up cigarette butts (£342 million), the cost of fires (£507 million),
the loss of economic output from the death of smokers (£4.1 billion), and
passive smokers (£713 million).
The study by Allender et al8 shows
the percentage attributable to smoking of total NHS costs for smoking-related
conditions in 2005–2006 by countries in UK (see Table 1). In England, the cost of smoking is £4.3 billion and
this represents about 85% of the total smoking attributable costs in UK. For
Wales, Scotland, and Northern Ireland, smoking-attributable cost was £234.2
million, £409.4 million and £127.9 million, respectively. Following the
analysis made by this study, the smoking-attributable fraction (SAF) in UK was
estimated at 23%. The SAF represents the costs attributable to smoking for
smoking-related conditions, as a proportion of total NHS expenditure for those
conditions. The smoking-related conditions considered included cardiovascular
diseases, COPD, other respiratory conditions, lung/bronchus/trachea cancer,
mouth and oral cancer and peptic ulcer disease.
In spite of the costs of smoking in UK,
there are potential economic benefits that smoking brings to the economy. Just
like in other countries, tobacco is a major revenue earner for the government.
Thus, a reduction in the prevalence of smoking will bring about significant
loss to the Exchequer. According to the HM Revenue and Customs112 Tobacco
Bulletin and Factsheets, the treasury earned £9.5 billion in revenue from
tobacco duties in the financial year 2011–2012 (excluding VAT). This amounts to
2% of the total government revenue. Including VAT at an estimated £2.6 billion,
total tobacco revenue was £12.1 billion.113 The
price of a pack of 20 premium brand cigarettes currently costs around £7.98, of
which £6.17 (or 77%) is tax.114 The
economic benefits of smoking from taxation alone thus appear to be noticeably
higher than the direct costs of smoking in UK. A CBA of the effects of
increasing tobacco taxation commissioned by ASH (in115)
found that a tobacco price increase of 5% would result in net benefits to the
economy as a whole of around £10.2 billion over 50 years. The economic benefits
in the first 5 years would be around £270 million per year on average.
Apart from government taxation, tobacco
companies make huge profits from sale of tobacco products. In 2012, British
American Tobacco, which is the world’s second largest tobacco company, produced
694 billion cigarettes worldwide (down from 705 billion in 2011) and reported
an operating profit of £5.14 billion, an increase of 15% on 2011.116 The
two major UK tobacco companies—Imperial Tobacco and Gallaher (the latter now
owned by JTI)—control around 85% of the UK market.
The economic benefits of smoking in UK
could also be seen in terms of employment in the tobacco and dependent
industries. According to the National Statistics from Tobacco Manufacturers
Association,117 approximately
5,700 people are employed in tobacco manufacturing in UK. It has been argued
that a reduction of smoking might not necessarily imply an overall increase in
unemployment. It may well boost employment and output.56,118,119 The
argument is that, though there will be loss of job in the tobacco industry
following smoking cessation, money not expended on tobacco will then be spent
elsewhere, thereby increasing the demand for other goods and services, and
hence generating employment for some other sectors. The extent, to which this
happens, however, depends on the spending patterns of the former smokers.
McNicoll and Boyle118 estimated
that a total cessation of cigarette purchases in Glasgow will bring about net
benefits to the Scottish economy. They estimated that for every £1 million
reduction in cigarette expenditure, there would be a net increase in Scottish
output of £1.1 million and a net increase of Scottish employment of 64 jobs. In
a similar study by Buck et al,119 a
40% reduction in smoking—a target set by the 1992 UK Policy document—will have
estimated effects of increasing jobs in the UK by 150,000. As noted earlier, a
smoking population also has the benefit of achieving savings in pension
payments from the premature death of smokers. Manning et al120 have
estimated that every pack of cigarettes smoked reduces the life expectancy by
137 minutes and pension costs by $1.82.
The effectiveness and cost effectiveness
of UK-specific smoking cessation programs
This section takes a look at the
effectiveness and cost effectiveness of smoking cessation interventions that
are specific to the UK and identifies where there are any cost savings or net
benefits to the health care system arising from a reduction in smoking
prevalence. It reviews high-quality evidence on the economics of smoking
cessation programs implemented in the different parts of UK. In 1998, the UK
government for the first time took a comprehensive approach to the reduction of
smoking prevalence in England when it published a policy paper (called a White
Paper), Smoking Kills. This program was aimed at reducing smoking
among children and adolescents, and help adult smokers, particularly the
disadvantaged ones (including pregnant women) to quit smoking. The strategy
involved ban on tobacco advertising, further increases in tobacco pricesg,
measures to reduce smoking in workplaces and in public places, measures to
restrict the sale of tobacco to minorsh,
and also, for the first time in the history of NHS, the commitment of huge
resources to smoking cessation treatment services. Smoking Kills has
been able to reduce the average prevalence of smoking in adults (16 years+) in
England from 27% before the implementation period to 21% in 2008.121
NHS smoking cessation treatment services
The White Paper, Smoking kills,
sets out guidelines for the provision of specialist smoking cessation services.
The United Kingdom was the first country to introduce a national smoking
cessation treatment program funded through public taxes.122 Since
then, other countries have implemented similar treatment services, eg, Japan
and Taiwan. Since 2000, many smokers have received behavioral support through
counseling or special training sessions to aid smoking cessation. In England
and other parts of UK, smokers can purchase NRT products from local pharmacies
and shops. A report from the National Institute for Clinical Excellence (NICE)123 in
March 2002 showed that NRT and bupropion are some of the most cost-effective
treatments of all pharmacological interventions. Their cost effectiveness has
been estimated by NICE in terms of cost per life year gained (LYG); NHS
treatment services produce a cost of about £3000 per LYG and about £2000 when
adjusted using UK discount rates (estimates cited in Ref. 124,
pp. 5). Stapleton125 reveals
that calculations based on the reported performance of the NHS specialist
smoking cessation services suggest they are highly cost effective, generating a
cost of less than £800 per life-year saved. The same study reveals that during
April 2000 and March 2001, about 126,800 smokers made an attempt to quit
smoking while attending cessation services. Of these, 48% were abstinent at the
end of 4 weeks. The total costs (including treatment and administrative costs)
were £21.4 million or £209 when expressed per patient treated.
According to a more recent report for
2005, an estimated 2 million smokers in UK used NRT products (and to a much
lesser extent bupropion) to aid in stopping smoking.122 The
effectiveness of these treatment services has also been estimated at ~2%–3%
abstinence rates. In all, about 90,000 smokers (out of an estimated 12 million
smokers in UK) stopped smoking permanently in 2005, implying that about 0.75%
of smokers became ex-smokers due to smoking cessation treatments.
Two very recent studies have also
examined the cost effectiveness of NRT, bupropion, and varenicle for preventing
or reducing relapse to smoking by abstinent smokers following smoking
cessation.27,126 Their
findings revealed that, like other interventions, relapse prevention
interventions (RPIs) are also likely to be highly cost and clinically
effective. When compared to no intervention, using bupropion for relapse
prevention resulted in an incremental QALY increase of 0.07 with a concurrent
NHS cost saving of £68; NRT and varenicline both caused incremental QALY
increases of 0.04 at costs of £12 and £90, respectively. Extensive sensitivity
analyses from both studies demonstrated that cost-effectiveness ratios were
more sensitive to variations in RPI effectiveness than cost. In addition, even
after varying key model parameters, the cost effectiveness of NRT and bupropion
generally remained. Cost effectiveness ratios only exceeded the UK NICE benchmark
of £20,000 per QALY when drug treatment effects were projected to last for only
1 year.
In summary, NHS treatment services and
relapse prevention intervention services have been both clinically and cost
effective, generating substantial health and cost savings that are acceptable
to health care providers.
Community pharmacy-based smoking
cessation
Crealey et al127 have
looked at the cost effectiveness of a community pharmacy-based smoking
cessation program in Northern Ireland. Data from a pilot study conducted in two
community pharmacies in Belfast were used as the basis of the current study,
which examined the costs and effects associated with a formal counseling
program for smoking cessation by community pharmacists across Northern Ireland.
The Pharmacists Action on Smoking (PAS) model was the only active intervention
used in the study. Findings indicate that the cost per life year saved when
using the PAS program ranges from £196.76 to £351.45 in men and from £181.35 to
£772.12 for women (1997 values), depending on age. This compares favorably with
other disease prevention medical interventions such as screening for
hypertension or hypercholesterolemia. More recently, Boyd and Briggs128 examined
the cost effectiveness of pharmacy-based versus group behavioral support in
smoking cessation services in Glasgow. This study was based on the premise that
smokers attending group-based support for smoking cessation are significantly
more likely to be successful than those attending pharmacy-based support. The
study was conducted using a combination of observational study data and
information from the NHS Greater Glasgow and Clyde smoking cessation services.
Findings revealed that incremental cost per 4-week quitter for pharmacy-based
support was found to be approximately £772 and £1612 for group support,
dismissing the earlier hypothesis. Furthermore, estimated incremental cost per
QALY for pharmacy-based service is £4400 and £5400 for group support service.
The study, however, concludes that both group support and pharmacy-based
support for smoking cessation are highly cost effective.
Action Heart promotion program
Action Heart is a cost-effective,
community-based heart promotion project, which was implemented between 1991 and
1995 in Wath and Swinton, England. Baxter et al129 carried
out a prospective comparative study to establish whether this community-based
coronary heart disease health promotion intervention, undertaken over 4 years,
was associated with a reduction in the prevalence in adults of risk factors
associated with heart disease, including smoking, as well as to estimate the
cost effectiveness of this intervention. Smoking prevalence before and after
the intervention was assessed using a questionnaire mailed to residents in both
the intervention and control areas. Smoking decreased in the intervention area
and increased in the control area between 1991 and 1995. Results showed that
the intervention achieved a smoking abstinence rate of 6.9%, while 8.7% more of
the sample population consumed low-fat milk between the intervention and
control area in the 4-year period. The differences between the areas rose from
4.2% to 9.2%. Total project cost (including allowances for community project
officer and worker, consumables and other overheads, other NHS staff, school
expenditure, etc) was £110,000. The estimated cost per life year gained was
£31.
Heart beat wales (HBW)
Phillips and Prowle22 also
appraised the economics of a no-smoking intervention program named Heart Beat
Wales (HBW) carried out between 1985 and 1988. Health benefits were estimated
as intermediate and final outcomes. Intermediate outcomes were the reduction in
the number of smokers and the amount of tobacco consumed. The final outcomes
were presented in the terms of reduced morbidity and mortality in three disease
groups—coronary heart disease (CHD), lung cancer, and chronic bronchitis. The
program costs included direct cash costs and staff costs. Total cost in year 1
was £72,000, in year 2 £82,000, in year 3 £150,000, and in year 4 £205,000.
Results show a net present value of benefits to NHS of £4,134,000. The “economic”
appraisal has a present value of benefits of £43,503,000. The estimated cost of
a working life year saved is £5.78. The net present value of benefits from
reductions in smoking is significantly greater than costs in terms of both the
NHS and the economy as a whole in Wales. In addition, the net costs per life
year saved reveals that the program generates additional working life years at
relatively low cost.
No smoking day
More than two decades after the launch
of the “No Smoking Day” (NSD) in UK, Owen and Youdan130 and
Kotz et al131 evaluated
the impact and relevance of this national awareness day. Launched in 1984, the
campaign seeks to create an enabling environment for smokers to quit smoking.
When the campaign began, smoking prevalence in the UK was more than 33% of
adults; in 2003 it dropped to 25%. The campaign expenditure ranges somewhere
between £470,000 and £550,000 annually. Results show that follow-up after 1
week indicates awareness of NSD is lower in 2004 than in 1986, 2 years after it
was launched. However, awareness is still high at 70% for all smokers. Interestingly,
the decline in participation from 18% of aware smokers in 1994 to 7% in 2001
was reversed in 2005 when about 19% either gave up or reduced their smoking on
NSD. In 2004, NSD awareness had reached 78% of the smoking population. When
compared to the 8.5 million smokers in England, the campaign can be deemed to
be effective in reaching its target audience. In addition, media coverage has
increased regardless of the fact that the campaign expenditure has remained
relatively constant and calls to national smokers’ helpline on NSD are
typically four times those received on a normal day. The cost of NSD per smoker
was £0.088. The discounted life years gained per smoker in the modal age group
35–44 years was 0.00107, resulting in an incremental cost–effectiveness ratio
(ICER) of £82.24 (95% CI 49.7–231.6). Thus, the campaign emerges as an
extremely effective and cost-effective public health intervention in aiding
smoking cessation.
HEBS’s mass media-led intervention
Ratcliffe et al132 evaluated
the costs and outcomes of a mass media-led antismoking campaign in Scotland,
which was conducted by the Health Education Board for Scotland (HEBS). The
campaign had three elements or features, namely 1) mass media advertising,
including television, outdoor posters, and press; 2) Smoke line, a free
telephone quit line to aid smoking cessation; and 3) You can stop smoking,
a practical handbook aimed at guiding smokers to renounce smoking. At the end
of a 12-month period, about 9.88% of individuals in the follow-up sample
reported they have renounced smoking since 6 months after the campaign. The
costs of the campaign (including the youth campaign costs) ranged from
£1,486,101 to £1,546,420. In terms of costs per quitter, estimates ranged from
£189 to £369. The costs per life year saved attributable to the campaign ranged
from £304 to £656. Another mass media campaign based on behavior change theory
and operating through both traditional and new media, known as Stoptober,
was launched in England during late 2012. Brown et al133 found
that Stoptober was both effective and cost effective, as it generated
up to 350,000 quit attempts and saved 10,400 discounted life years (DLY) at
less than £415 per DLY in the modal age group.
This section has reviewed the economic
impact of smoking and reducing its prevalence in UK. Though smoking is
beneficial to the UK both in terms of tax revenue and employment, the health-
and non-health-related costs of smoking to the NHS and the society far outweigh
any benefits that might be accruable at least from a socially desirable
perspective. Most smoking cessation interventions implemented in the UK have
also been highly effective, reducing the number of smokers and any health risks
associated with smoking.
Discussion
This study reviews major studies on the
economics of tobacco smoking and the economic impact of reducing its prevalence
both globally and in UK. The findings from the review reveal that tobacco
smoking is the cause of many preventable diseases and premature deaths in UK
and around the world. It poses enormous health- and non-health-related costs to
the affected individuals, employers, and the society at large. The WHO
estimates that, globally, smoking causes over US$500 billion in economic damage
each year. In the UK, the total estimated costs of smoking to society could be
put at £13.74 billion. In the US, a much larger economy by population and GDP,
the social cost of smoking is more than 8 times that of UK—US$193 billion (or
~£114 billion) according to estimates from Kahende et al,5 though
this figure is even larger when we consider latest estimates from the Campaign
for Tobacco-Free Kids, which puts the social cost of smoking at US$321 billion.59 About
15% of the aggregate health care expenditure in high-income countries can be
attributed to smoking. In the US, the proportion of health care expenditure
attributable to smoking ranges between 6% and 18% across different states. In
the UK, the direct costs of smoking to the NHS have been estimated at between
£2.7 billion and £5.2 billion, which is equivalent to around 5% of the total
NHS budget each year. The economic burden of smoking estimated in terms of GDP
reveals that smoking accounts for approximately 0.7% of China’s GDP and
approximately 1% of US GDP. As part of the indirect (non-health-related) costs
of smoking, the total productivity losses caused by smoking each year in the US
have been estimated at US$151 billion. Smoking is therefore considerably
expensive to countries where its prevalence is high, particularly high-income
countries. The costs notwithstanding, smoking has some potential economic
benefits to most economies. The economic activities generated from the
production and consumption of tobacco provides economic stimulus. It also
produces huge tax revenues for most governments, especially in high-income
countries, as well as employment in the tobacco industry. Income from the
tobacco industry accounts for up to 7.4% of centrally collected government
revenue in China. Smoking also yields cost savings in pension payments from the
premature death of smokers.
Several measures have been undertaken by
most countries (including UK) over the years in order to reduce the prevalence
of smoking in adults, children, and pregnant women. These measures range from
pharmacological treatment interventions (such as the use of NRT, bupropion, and
vernicle) to policy-based measures (tax increases, smoking restrictions, bans
on tobacco advertising, etc.), community-based interventions (such as smoking
cessation contests, classroom education, self-help quit kit, etc.), TMT-based
measures (such as quitlines, mass media led interventions, internet- and
computer-based measures), school-based measures, and workplace interventions.
We now discuss some of the findings from the review by comparing results across
types of intervention, implementation countries, and measurement outcomes,
where possible.
Comparing the effectiveness and cost
effectiveness of various interventions
From the review of pharmacological and
medical treatment interventions for smoking cessation across countries, it was
found that cost per life year saved ranged between US$128 and US$1,450 and up
to US$4,400 per QALY saved. Comparing various types of pharmacological
interventions, existing studies showed that varenicline (with or without
behavioral interventions) seemed to be the most cost-effective therapy,
followed by bupropion and NRT. However, the results have a high risk of bias
because the manufacturer of varenicline funded most of the studies comparing
varenicline with bupropion or NRT. In the UK, it was found that the use of NRT
and/or bupropion combined with GP counseling was both clinically effective and
cost effective to primary health care providers.
Some studies reveal that pharmacological
treatments tend to yield more positive results in terms of number of quitters
than other cessation interventions (eg, NRT programs could yield as much as
18,500 quitters at a cost of US$4,440 per QALY compared to implementing a
smoke-free workplace policy, which would generate 10,400 quitters at US$506 per
QALY). The use of pharmacotherapies such as varenicline when combined with
other behavioral treatment interventions (such as proactive telephone counseling
and Web-based delivery, or both) is cost effective when measured from both cost
per LY and cost per QALY, with costs per additional 6-month nonsmoker and per
additional life time quitter ranging from US$1,278 to US$1,617 and from
US$2,601 to US$3,291, respectively.
With respect to policy-based measures,
increase in tobacco taxes is unarguably the most effective means of reducing
the consumption of tobacco and hence the health care costs associated with
treating smoking-caused diseases. Findings show that a 10% tax-induced
cigarette price increase anywhere in the world reduces smoking prevalence by
between 4% and 8%. Apart from reducing the number of smokers and saving lives,
increasing tobacco taxes also raise government revenue accruable from tobacco
manufacturers and retailers. Thus, as cigarette taxes increase, government tax
revenues continue to rise even as smoking prevalence falls. In fact, net public
benefits from tobacco tax remain positive only when tax rates are between 42.9%
and 91.1%. However, increase in tobacco taxes increases the risk of reduction
in employment in tobacco companies and the incidence of cigarette smuggling and
tax evasion, further dwindling the net benefits from tax increases.
Non-price-based measures (such as smoking restrictions in work places, public
places, bans on tobacco advertisement, and raising the legal age of smokers)
have also proven to be both effective and cost saving. The health and economic
benefits of such measures include reduction in smoking prevalence, reduction in
second hand smoke, savings from smoking-related medical expenditures, heart
diseases averted, costs averted by a reduction in smoking-induced fires, and
gains in productivity. Findings show that the cost–effectiveness ratio of
implementing non-price-based smoking cessation legislations range from US$2 to
US$112 per LYG, while reducing smoking prevalence by up to 30%–82% in the long
term (over 50-year period).
From the perspective of the public
health system, community-based intervention programs yield cost savings and
life year gains. There are, however, differences in the effectiveness and cost
effectiveness of different types of community-based interventions. Smoking
cessation classes are known to be most effective among community-based measures
since they require more time commitment from participants. They could lead to a
quit rate of up to 35%, but they usually incur higher costs. On the other hand,
self-help quit smoking kits usually require the lowest time commitment from
participants and are usually the most cost effective. Community pharmacies also
provide opportunities for regular contact with residents of a local community.
On average, community pharmacist-based smoking cessation programs yield cost
savings to the health system of between US$500 and US$614 per LYG. Knowledge of
the health and economic gains of different community-based measures is highly
desirable when health policy decision makers plan the allocation of resources
for smoking cessation at the community level. One classic example of an
effective community-based campaign is the UK’s “No Smoking Day”. After almost
three decades of its launch, the campaign has achieved a 78% awareness rate. It
has also reduced smoking prevalence by 14%. With the cost of NSD per smoker at
£0.088 and ICER of £82.24, NSD emerges as an extremely cost-effective public
health intervention.
Since many people are ambivalent about
smoking, it has been widely held that advertising media, telecommunications,
and other technology-based interventions usually have positive synergistic
effects. In fact, as many studies show, an integrated approach involving a
combination of multiple media to deliver a message produces greater effects
than relying on one medium alone. However, the outcomes on the effectiveness and
cost effectiveness of TMT-based measures have been inconsistent. For example,
Farrelly et al92 examined
the effects of expenditure on TV, radio, and print advertising and concluded
that, while TV advertising produced the greatest yielded proportionally higher
increases in the call rate. Clayforth et al42 found
that online-only advertising campaigns can be substantially more cost effective
than other non-television advertising media such as radio, and print media,
including when an integrated approach is used. Chen et al34,35 also
found that making some form of electronic support available to smokers actively
seeking to quit (e.g., PC, internet, and other electronic aids) is highly
likely to be cost effective. This is true whether the electronic intervention
is delivered alongside brief advice or more intensive counseling.
The differences in reported cost
effectiveness may be partly attributed to varying methodological approaches,
including different inputs used to determine model parameters, especially the
different dependent variables tested (e.g., calls to a quit line versus
intention to quit; visits to a quit website versus online registration to
smoking cessation services), disparate levels of resourcing between campaigns,
differences in national contexts, and differences in advertising campaigns
tested on different media. For example, radio is limited to sound, while
traditional print media is confined to static pictures. Further, it is
difficult to isolate the effects of individual media due to the tendency for
campaigns to typically involve the simultaneous use of different media to
optimize results. In such circumstances, it is difficult to attribute results
to specific media. Some studies have, however, shown that under a wide variety
of conditions, the use of personalized smoking cessation service advice, when
combined with telephone counseling, mobile phone messages, or other personalized
computer-based intervention measures, is both beneficial for health and cost
saving to a health system.
In evaluating the effectiveness of
school-based intervention programs aimed at preventing smoking in children and
adolescents, many studies have conducted analysis of peer-led programs,
analysis of social influences, social competences, gender effects, class
competitions, and booster sessions, among other measures. Thomas et al98 found
that all these theoretical approaches were very effective in aiding smoking
cessation particularly in the number of youths that were prevented from
starting smoking. Numerous smoking prevalence trials have found short-term
decreases in smoking prevalence of between 30% and 70%. As with other
intervention programs, determining that a program is effective may not be
sufficient to justify its implementation since the resources to fund
school-based smoking prevention programs are limited. Because of limited
financial resources, most school-based smoking cessation programs are usually
carried out in multiple schools, most times covering thousands of students
across communities or regions within the countries of implementation (eg, TNT in
USA; ASSIST in England and Wales; MYTRI in India; SFC in Germany). Total
intervention costs could range from US$16,400 to US$580,000 depending on the
scale and scope of intervention, and these costs usually cover personnel
expenses, costs of materials, travel expenses, and program administration
costs. Most studies evaluating the cost effectiveness of school-based programs
show that one could expect a saving of approximately between US$2,000 and
US$20,000 per QALY saved due to averted smoking after 2–4 years of follow-up.
Finally, from the economic evaluation of
smoking cessation activities at the workplace, it is evident that
employer-based interventions could be beneficial to both employers and the
society at large. For example, Warner et al105 found
that smoking cessation is a very sound economic investment for the firm, and is
particularly profitable when long-term benefits are included, with an eventual
benefit–cost ratio of 8.75. Jackson et al107 also
showed that pharmacological interventions at the workplace seemed to generate
12-month employer cost savings per nonsmoking employee of between $150 and
$540. Other studies by Ong and Glantz108 also
showed that the first-year effect of making all workplaces in the US smoke-free
would produce about 1.3 million new quitters and prevent over 950 million
cigarette packs from being smoked annually, worth about US$2.3 billion in
pretax sales to the tobacco industry. In addition to preventing the risk of
smoking-induced diseases such as myocardial infarction and strokes, smoke-free
work places could result in nearly US$49 million in savings in direct medical
costs after 1 year. At steady state, more than US$224 million would be saved in
direct medical costs annually.
From a review of these and other
economic studies, it can be safely deduced that the economic benefits of
employer-based smoking cessation measures are likely to be far more greater
than the costs involved, particularly on a long-range basis, since reduced
worksite smoking prevalence translates into reduced absenteeism, increased
productivity, lower health insurance costs, higher cost savings, and higher
overall benefit–cost ratio in the long run. Moreover, the economic advantages
of workplace anti-tobacco policies seem to be more visible when smoking at the
workplace is completely prohibited and no smoking areas are set.
Limitations of the study
Only a few studies examining the
long-term effect of smoking cessation interventions were found. Evidence of
long-term health and economic benefits of many cessation interventions such as
clinical and workplace interventions remains uncertain. A series of sensitivity
analyses from many of the studies also show that both cost savings and life
year gains are sensitive to variations in the discount rates and the long-term
smoking quit rate associated with the intervention. Thus, there is a high risk
of uncertainty in some of the cost estimates provided in this study. Another
source of error in comparative analysis is the differences in basis for cost
comparisons across countries and the impact of inflation on cost estimates. For
example, there are significant differences across countries in terms of basic
demographic and socioeconomic characteristics, life expectancy of population,
and advancements in health care systems. Thus, calculation of life years saved
and medical costs of smoking-related diseases are likely to differ
significantly across countries. Also, the inflation rates in
developing/emerging countries like India, Thailand, Taiwan, and China are
likely to be higher than those in developed countries such as USA, UK, Canada,
and Australia where inflation rates are known to be somewhat lower. Hence, some
studies may overstate the real cost estimates if not properly discounted (ie,
adjusted) for inflation, thus making comparisons across time and countries
difficult. Finally, it is worth noting that the results of many studies
reviewed may not have been well established quantitatively in the sense that
most of these studies reflect potential uncertainty in the estimates and data
used and, in some cases, data sufficient to establish definite causality are
lacking.
Conclusions
Though tobacco smoking may be
economically beneficial, its direct costs and externalities to society far
outweigh any benefits that might be accruable at least when considered from the
perspective of socially desirable outcomes (e.g., a healthy population and a
vibrant workforce). There are enormous differences in the application and
economic measurement of smoking cessation measures across various types of
interventions, methodologies, countries, economic settings, and health care
systems, and these may have affected the comparability of the results of the
studies reviewed. However, on the balance of probabilities, most of the
cessation measures reviewed have not only proved effective but also cost
effective in delivering the much-desired cost savings and net gains to
individuals and primary health care providers.
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