The economics of smoking and cardiovascular disease

The economic burden of exposure to secondhand smoke for child and adult never smokers residing in U.S. public housing

OBJECTIVE

The World Health Organization (WHO) reports that nonsmokers experience disease and death due to secondhand smoke (SHS) exposure in the home. We estimated the total excess burden and costs to society due to SHS exposure in U.S. public housing.

METHODS

We quantified the public health burden for outcomes causally related to SHS exposure for nationally representative never-smoking residents in U.S. public housing using (1) WHO-recommended health outcomes and methodology, (2) publicly available and other large databases, and (3) published estimates of morbidity and mortality rates. We used published estimates of direct medical and nonmedical care costs and the value of productivity losses to estimate SHS-related societal costs for disease and death. We estimated the public health and economic burden for two serum cotinine limits of detection (LODs): 0.05 nanograms per milliliter (ng/mL) and 0.015 ng/mL.

RESULTS

In 2011, an estimated 37,791 never-smoking child and adult U.S. public housing residents experienced illness and death due to SHS exposure at home based on an LOD=0.05 ng/mL (50,967 residents at LOD=0.015 ng/mL). Costs incurred by society for these illnesses and deaths totaled $183 million (LOD=0.05 ng/mL) and $267 million (LOD=0.015 ng/mL) annually. Of the total costs, direct costs (medical and nonmedical) accounted for $128 million and $176 million for LOD=0.05 ng/mL and LOD=0.015 ng/mL, respectively. Medical care accounted for the majority of direct costs-$110 million at LOD=0.05 ng/mL and $153 million at LOD=0.015 ng/mL. Adverse respiratory health outcomes accounted for approximately one-half (56% at LOD=0.05 ng/mL and 52% at LOD=0.015 ng/mL) of total societal costs.

CONCLUSION

Implementing smoke-free policies in all U.S. public housing could save lives and decrease SHS-related morbidity and mortality in never-smoking residents, resulting in annual societal savings of $183 million at LOD=0.05 ng/mL and $267 million at LOD=0.015 ng/mL.

A graphical, computer-based decision-support tool to help decision makers evaluate policy options relating to physical activity

This pilot study builds on efforts to develop evaluation methods to compare and contrast potential strategies designed to increase population physical activity generally, and to reduce disparities in activity levels more specifically. The study presents a user-friendly, semi-quantitative decision-support tool of intermediate complexity that may better enable quick, flexible first-pass "ballpark" decision making by state and local health agencies instead of traditional evidence-based scientific reviews. The tool produces a summary score from ratings on 18 criteria, adjusted by fixed or variable weights to incorporate salient community contextual factors. Stair use, workplace activity breaks, and school construction siting are presented as samples. This first iteration of the decision-support tool is intended to be refined empirically by the experiences and policy outcomes of agencies adopting the innovation. This decision-support tool may expand the capacity of public health practitioners to conduct first-pass assessments of policy options for physical activity promotion in underserved communities.

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

OBJECTIVE

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

RESEARCH DESIGN AND METHODS

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

RESULTS

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

CONCLUSION

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

The control of environmental tobacco smoke: a policy review

According to World Health Organisation figures, 30% of all cancer deaths, 20% of all coronary heart diseases and strokes and 80% of all chronic obstructive pulmonary disease are caused by cigarette smoking. Environmental Tobacco Smoke (ETS) exposure has also been shown to be associated with disease and premature death in non-smokers. In response to this environmental health issue, several countries have brought about a smoking ban policy in public places and in the workplace. Countries such as the U.S., France, Italy, Ireland, Malta, the Netherlands, Sweden, Scotland, Spain, and England have all introduced policies aimed at reducing the population exposure to ETS. Several investigations have monitored the effectiveness of these smoking ban policies in terms of ETS concentrations, human health and smoking prevalence, while others have also investigated a number of alternatives to smoking ban policy measures. This paper reviews the state of the art in research, carried out in the field of ETS, smoking bans and Tobacco Control to date and highlights the need for future research in the area.

Costs of heart disease and risk behaviour: implications for expenditure on prevention

AIMS

The objective of this paper is firstly to estimate the healthcare costs attributable to heart disease in Denmark using recently available data for 2002-05. Secondly, to estimate the attributable healthcare costs of lifestyle risk factors among heart patients, in order to inform decision making about prevention programmes specifically targeting patients with heart disease.

METHODS

For a cohort consisting of participants in a national representative health interview survey, register-based information about hospital diagnosis was used to identify patients with heart disease. Healthcare consumption during 2002- 05 among individuals developing heart disease during 2002-05 was compared with individuals free of heart disease. Healthcare costs attributable to heart disease were estimated by linear regression with adjustment for confounding factors. The attributable costs of excess drinking, physical inactivity and smoking among future heart patients were estimated with the same method.

RESULTS

Individuals with heart disease cost the healthcare system on average 3,195 (p<0.0001) per person-year more than individuals without heart disease. The attributable cost of unhealthy lifestyle factors among individuals at risk of heart disease was about 11%-16% of the attributable cost of heart disease.

CONCLUSIONS

Heart disease incurs significant additional costs to the healthcare sector, and more so if heart patients have a history of leading an unhealthy life. Consequently, strategies to prevent or cease unhealthy lifestyle may not only result in cost savings due to avoided heart disease. Additional cost savings may be obtained because heart patients who prior to the disease led a more healthy life consume fewer healthcare resources.

Costs of stroke using patient-level data: a critical review of the literature

BACKGROUND AND PURPOSE

With decision-analytic models becoming more popular to assess the cost-effectiveness of health care interventions, the need for robust estimates on the costs of cerebrovascular disease is paramount. This study reports the results from a literature review of the costs of cerebrovascular diseases, and assesses the quality of the published evidence against a set of defined criteria.

METHODS

A broad literature search was conducted. Those studies reporting mean/median costs of cerebrovascular diseases derived from patient-level data in a developed country setting were included. Data were abstracted using standardized reporting forms and assessed against 4 predefined criteria: use of adequate methodologies, use of a population-based study, inclusion of premorbid resource use, and reporting of costs by different patient subgroups.

RESULTS

A total of 120 cost studies were identified. The cost estimates of stroke were compared by taking into account the effects of inflation and price differentials between countries. Average costs of stroke ranged from $468 to $146 149. Differences in costs were also found within country, with estimates in the USA varying 20-fold. Although the costing methodologies used were generally appropriate, only 5 studies were based on population-based studies, which are the gold standard study design when comparing incidence, outcome, and costs.

CONCLUSIONS

This review showed large variations in the costs of stroke, mainly attributable to differences in the populations studied, methods, and cost categories included. The wide range of cost estimates could lead to selection bias in secondary health economic analyses, with authors including those costs that are more likely to produce the desired results.

Lipid-soluble smoke particles upregulate vascular smooth muscle ETB receptors via activation of mitogen-activating protein kinases and NF-kappaB pathways

Cigarette smoke is a strong risk factor for cardiovascular disease. However, the underlying molecular mechanisms that lead to cigarette smoke-associated cardiovascular disease remain elusive. With functional and molecular methods, we demonstrate for the first time that lipid-soluble cigarette smoke particles (dimethylsulfoxide-soluble cigarette smoke particles; DSP) increased the expression of endothelin type B (ET(B)) receptors in arterial smooth muscle cells. The increased ET(B) receptors in arterial smooth muscle cells was documented as enhanced contractility (sensitive myograph technique), elevated levels of ET(B) receptor mRNA (quantitative real-time PCR), and protein expressions (immunohistochemistry and Western blotting). Intracellular signaling was studied with Western blotting and phosphoELISA; this revealed that DSP induced extracellular-regulated protein kinases 1 and 2 (ERK1/2), p38, and nuclear factor-kappaB (NF-kappaB) phosphorylation within 3 h. Blocking ERK1/2, p38, or NF-kappaB activation by their specific inhibitors significantly attenuated the DSP-induced upregulation of ET(B) receptor-mediated contraction and both ET(B) receptor mRNA and protein expression. In addition, dexamethasone abolished the DSP-induced upregulation of ET(B) receptor-mediated contraction. In conclusion, upregulation of ET(B) receptors by DSP in arterial smooth muscle cells involves activation of mitogen-activating protein kinases (ERK1/2 and p38) and the downstream transcriptional factor NF-kappaB pathways.

A clinical practice guideline for treating tobacco use and dependence: 2008 update. A U.S. Public Health Service report

OBJECTIVE

To summarize the U.S. Public Health Service guideline Treating Tobacco Use and Dependence: 2008 Update, which provides recommendations for clinical interventions and system changes to promote the treatment of tobacco dependence.

PARTICIPANTS

An independent panel of 24 scientists and clinicians selected by the U.S. Agency for Healthcare Research and Quality on behalf of the U.S. Public Health Service. A consortium of eight governmental and nonprofit organizations sponsored the update.

EVIDENCE

Approximately 8700 English-language, peer-reviewed articles and abstracts, published between 1975 and 2007, were reviewed for data that addressed assessment and treatment of tobacco dependence. This literature served as the basis for more than 35 meta-analyses.

CONSENSUS PROCESS

Two panel meetings and numerous conference calls and staff meetings were held to evaluate meta-analyses and relevant literature, to synthesize the results, and to develop recommendations. The updated guideline was then externally reviewed by more than 90 experts, made available for public comment, and revised.

CONCLUSIONS

This evidence-based, updated guideline provides specific recommendations regarding brief and intensive tobacco-cessation interventions as well as system-level changes designed to promote the assessment and treatment of tobacco use. Brief clinical approaches for patients willing and unwilling to quit are described.

Up-regulation of thromboxane A2 receptor expression by lipid soluble smoking particles through post-transcriptional mechanisms

Atherosclerosis is a key factor in vascular disease, and cigarette smoking is a well-known risk factor that may induce an inflammatory response and enhance plaque formation in arteries. Thromboxane (Tx) is one key inflammatory mediator involved in the pathogenesis of cardiovascular disease. The present study was designed to test if lipid soluble smoking particles (DSP) enhance TxA(2) receptor (TP) expression in rat mesenteric arteries, and if intracellular mitogen-activated protein kinase (MAPK) pathways play a role. Organ culture of rat mesenteric arteries in the presence of DSP (0.2 microl/ml for 24h) resulted in markedly elevated contractile responses to the Tx analog U46619, compared with the control DMSO. There was no increase in TP receptor mRNA expression, while the protein expression was significantly enhanced. This up-regulation was not affected by a general transcriptional inhibitor actinomycin D, but was almost completely abolished by cycloheximide, a general translational inhibitor. Dexamethasone, a glucocorticoid, manifested a potent inhibitory effect as well. These results suggest that the up-regulation of TP receptor occurs via post-transcriptional events, and mainly translation. This is supported by experiments with specific inhibitors for c-Jun-NH(2)-terminal kinase (SP600125), extracellular signal-regulated kinase 1 and 2 (PD98059 and U0126) and p38 (SB203580) that had no inhibitory effect on the up-regulation of TP receptors. Collectively, the results show that MAPK pathways are not involved in TP receptor up-regulation. Study on TP receptor mRNA stability showed that during organ culture, the TP receptor mRNA was stable in both DMSO and DSP group, but the latter elicited a tendency to stabilize the TP receptor mRNA at higher level. Thus, post-transcriptional mechanisms are responsible for the up-regulation of TP receptor by DSP, in which enhanced translation is the major cause of the elevated protein expression and the enhanced contraction.

Acute coronary syndromes in Europe: 1-year costs and outcomes

OBJECTIVE

This study aims to estimate costs (including medications prescribed, intervention rates and hospital utilization) and health outcomes of acute coronary syndromes (ACS) during the first year following diagnosis.

RESEARCH DESIGN AND METHODS

Treatment pathways for ACS patients were developed and country-specific resource use was multiplied by unit costs. Countries examined were the United Kingdom (UK), France, Germany, Italy and Spain. Patients with unstable angina and acute myocardial infarction (ST-segment elevation and non-ST-segment elevation with/without Q-wave) were considered. The study models the incidence of ACS, 1-year mortality, investigations, revascularisation, pharmaceutical use and medical management. Economic outcomes were direct healthcare costs (in 2004 Euros), including total cost, cost per patient with ACS and cost per capita.

RESULTS

The estimated number of deaths in the first year following ACS diagnosis ranged from around 22 500 in Spain to over 90 000 in Germany. The largest contributors to total costs are hospital stay and revascularisation procedures. Pharmaceuticals were estimated at 14-25% of ACS total cost. The total cost of ACS in the UK is estimated around 1.9 billion Euros, compared with 1.3 billion Euros in France, 3.3 billion Euros in Germany, 3.1 billion Euros in Italy and 1.0 billion Euros in Spain. The cost per ACS patient ranges from 7009 Euros (in the UK) to 12,086 Euros (Italy).

CONCLUSIONS

Countries with higher expenditure on ACS patients tended to have lower case-fatality rates, and countries with the lowest incidence of ACS also had the lowest cost per capita. The costs of ACS constitute a large proportion of total healthcare expenditure of Western European economies.

A Clinical Imperative: Assisting Patients Who Smoke to Reduce Their Risk of Cardiovascular Disease

The role of tobacco smoking as a cause of cardiovascular disease is now unequivocal and well-documented in literally hundreds of epidemiologic and biomedical studies over the past 50 years. Cessation of smoking, on the other hand, swiftly and profoundly reduces the risks of a cardiovascular event. Thus, smoking cessation should be seen as perhaps the most effective lifesaving intervention in the physician's armamentarium. Despite this widely available knowledge, and evidence that most smokers want to quit, relatively few physicians offer cessation support to their smoking patients, even those at high risk for a cardiovascular event. This article reviews the links between tobacco smoking and cardiovascular disease, argues for a greater role for physicians in assisting smokers to quit, and highlights the most effective interventions currently available.

[The cost of complications: implications for the measurement of the cost of type II diabetes mellitus]

BACKGROUND

A well-known methodology used to compute the macroeconomic cost of risk factors is the etiologic cost ratio, leading to estimates based on data on the prevalence of the risk factor in the general population, the relative risk of complications associated to it and the cost of the complications. A major problem of this method is that it is in some extent inconsistent with recent findings showing an increase in the per capita cost of some complications in presence of type II diabetes mellitus. The aim of the paper is to reconcile the approach with most recent economic studies and to overview the consequences of such an attempt in terms of methodological framework.

METHODS

We developed a methodological framework introducing heterogeneity in the cost of treating complications according to the presence of diabetes. We estimated the macroeconomic cost of type II diabetes mellitus based on selected complications (stroke, myocardial infarction, nephropathy and peripheral arterial obstructive disease) from French representative data in two situations: a situation in which the heterogeneity is not taken into account, another situation in which heterogeneity is introduced.

RESULTS

Our results point out that the assumption of homogeneity in the cost of complications is associated to an underestimation of the cost of diabetes by about 30%.

CONCLUSION

Our results present an attempt to reconcile the economic modeling of the cost of type II diabetes mellitus with the "real world". We conclude that the introduction of heterogeneity is necessary to capture the whole extent of the economic burden of the disease and that it places significant constraints on the data and the methodological framework to be used in such attempts.

Kosteneffektivität der Prävention der koronaren Herzkrankheit in Deutschland

It is generally accepted that the incidence of coronary heart disease can effectively be reduced by strengthening prevention. At the same time, it is still unclear how large the effects of life-style oriented preventive measurements such as diet and exercising are in everyday life. Furthermore, there is an ongoing debate on what measurements are effective. Thus, against the background of dwindling financial resources in health care the input of health economic evaluation is explicated. General issues of health economic evaluation are presented. After that, an overview on the current findings of cost-effectiveness in primary prevention of coronary heart disease is given. Risk factors are separately discussed. It is demonstrated that preventive measurements dealing especially with hypertension and hypercholesterolemia can be cost-effective.