Smoking cessation guideline cost-effective

Implementation could gain 1.7 million new quitters

Implementation of the recent smoking cessation guideline from the Rockville, MD-based Agency for Health Care Policy and Research could gain 1.7 million new quitters at a total cost of $6.3 billion in the first year, according to a new study in the Journal of the American Medical Association.1 That makes smoking cessation the most cost-effective intervention, with a cost per quitter of $3,779 or $2,587 for every life-year saved.

For comparison, the estimated cost per life-year saved by annual mammography for women ages 40-49 is $61,744, and the cost per life-year saved by hypertension screening for 40-year-old men is $23,335. Medical costs for smokers reach $50 billion annually, with an additional $47 billion for indirect expenses such as time lost from work and disability.

"We know smoking cessation is important from a clinical point of view, and we have now demonstrated that it also makes sense from a cost point of view," says Michael Fiore, MD, MPH, director of the Center for Tobacco Research and Intervention at the University of Wisconsin Medical School in Madison. Fiore was the panel chairman for the AHCPR smoking cessation guideline and an author of the study.

"There is not a single preventive intervention a clinician in America can do today that is as cost-effective as smoking cessation counseling and treatment. This study provides an even more powerful incentive for physicians to do the right thing, and that is to be actively involved in promoting smoking cessation among their patients."

The AHCPR released its first smoking cessation guideline in 1996, giving clinicians the ability to put the weight of more than 3,000 scientific articles behind their efforts to get patients to stop smoking. At their fingertips, clinicians had simple, effective suggestions based on a comprehensive literature review, such as asking every patient at every visit if they smoke and recording smoking status as a vital sign.

Because there are no claims data to quantify current practice - most physician counseling isn't billed separately, and many insurers don't cover smoking cessation therapy - the cost and effectiveness measures were based on estimates in the guideline, says Jerry Cromwell, PhD, lead author and president of Health Economics Research in Waltham, MA. Researchers used two approaches: One, they asked what would happen if all smokers could be encouraged to undertake one of the guideline's interventions and then compared resulting cost-effectiveness ratios across all interventions. Two, they asked a 20-expert panel what the likelihood would be of a patient choosing one of the interventions and used the probabilities to weight the costs and quit rates of those interventions. Cromwell developed a quality-adjusted life-year model to accommodate not only for longer life but also for better quality of life for quitters.

"Life expectancy alone underestimates the benefits of quitting smoking," Cromwell says. "The quit rate doesn't tell how much society benefits. If there were no harmful effects from smoking, who cares about the quit rate. We needed to show the connection between quit rates and better morbidity and mortality to draw final conclusions on effectiveness."

What they found was that the more intensive the intervention, the lower the cost. Costs ranged from $2,186 per quitter for group intensive counseling to $7,922 for minimal counseling. Spending more time resulted in greater benefits, but even small efforts pay off, Cromwell says. "Even with a physician spending just a few minutes with a patient, the costs are minimal, and the benefits of even one quitter are quite large," he says. "You get a big bang for your buck even with a small intervention."

The type of intervention depends on the smoker as much as the physician, Cromwell says. Group intensive cessation counseling had the lowest cost per quitter, but only 5% of smokers appear willing to put in that much time and effort. Group counseling is most cost-effective because it is intense, and its costs are spread out over the entire group of patients. Adding drug therapy, such as the nicotine patch, to the intervention costs more, for a total of $2,310 per quitter, but also increases effectiveness substantially.

Cromwell and Fiore say they hope the study will give physicians further incentives to help their patients quit smoking. They also hope the cost-effectiveness information will encourage more insurers to cover smoking cessation. Now, only about half cover AHCPR-recommended treatments, Fiore says, because the cost benefits usually aren't immediate. "Our hope is that the information will serve as an economic prompt for MCOs to do the right thing," he says.

[For more information on smoking cessation, contact: Michael Fiore, MD, MPH, director of the Center for Tobacco Research and Intervention, 1300 University Ave., Room 7278, MSC, Madison, WI 53706. Telephone: (608) 262-8673. Jerry Cromwell, PhD, president, Health Economics Research, 411 Waverley Oaks, Suite 330, Waltham, MA 02154. Telephone: (781) 487-0200, ext. 131. Harriett Bennett, smoking cessation liaison, Agency for Health Care Policy and Research, 2101 E. Jefferson St., Suite 501, Rockville, MD 20852. Telephone: (301) 594-1364, ext. 1371.]


1. Cromwell, "Cost-effectiveness of the Clinical Practice Recommendations in the AHCPR Guideline for Smoking Cessation," JAMA 1997; 278:1,759-1,766.