Cost-effectiveness and cost-utility analysis of a work-place smoking cessation intervention with and without financial incentives

Collaboration between occupational health professionals in smoking cessation treatment and support

BACKGROUND

Promoting health is an important part of occupational health (OH) professionals' daily practice. Occupational health services (OHS) support work ability and prevent both work-related diseases and lifestyle-related illnesses.

OBJECTIVE

We focused on how interprofessional collaboration (IPC), regardless of whether the OHS provider is public, private or in-house, influences the implementation of smoking cessation treatment and support (SCTS). We studied IPC of OH professionals in SCTS and whether they differ depending on OHS providers.

METHODS

We collected data through an online survey of a cross-sectional sample of OH professionals of physicians (n = 182), nurses (n = 296) and physiotherapists (n = 96) at two different time-points, in 2013 and 2017. The questionnaire contained questions on interprofessional SCTS practices, so that we could assess how the professionals' experiences differed from each other. We used explanatory factor analysis to study the collaboration, and the Kruskall-Wallis test to detect the differences between the OH professional groups as a post-hoc data analysis.

Background

OH physicians (mean 3.4, SD 1.2) and OH nurses (mean 3.2, SD 1.1) experienced smooth collaboration in SCTS whereas OH physiotherapists (mean 2.5, SD 1.1) felt excluded from IPC. In-house OH centres (mean 3.5, SD 1.0) seemed to offer the best opportunities for implementing IPC in SCTS comparing to public (mean 3.1, SD 0.9) or private (mean 2.9, SD 0.9) OHS.

CONCLUSION

The IPC of OH professionals in SCTS interventions need to be rearranged. This requires boundary-crossing SCTS practices involving all professionals. All OH professionals should implement IPC in SCTS and share their specific competence.

Clinical Practice Guideline of Spanish Society of Pneumology and Thoracic Surgery (SEPAR) on Pharmacological Treatment of Tobacco Dependence 2023

INTRODUCTION

There are multiple systematic reviews and meta-analyses on the efficacy and safety of pharmacological treatments against nicotine dependence. However, there are few guidelines to answer frequent questions asked by a clinician treating a smoker. Therefore, the aim of this paper is to facilitate the treatment of tobacco addiction.

MATERIAL AND METHODS

12 PICO questions are formulated from a GLOBAL PICO question: "Efficacy and safety of pharmacological treatment of tobacco dependence". A systematic review was carried out to answer each of the questions and recommendations were made. The GRADE (Grading of Recommendations, Assessment, Development and Evaluation) system was used to grade the certainty of the estimated effects and the strength of the recommendations.

RESULTS

Varenicline, nicotine replacement therapy (NRT), bupropion and cytisine are more effective than placebo. Varenicline and combined nicotine therapy are superior to the other therapies. In smokers with high dependence, a combination of drugs is recommended, being more effective those associations containing varenicline. Other optimization strategies with lower efficacy consist of increasing the doses, the duration, or retreat with varenicline. In specific populations varenicline or NRT is recommended. In hospitalized, the treatment of choice is NRT. In pregnancy it is indicated to prioritize behavioral treatment. The financing of smoking cessation treatments increases the number of smokers who quit smoking. There is no scientific evidence of the efficacy of pharmacological treatment of smoking cessation in adolescents.

CONCLUSIONS

The answers to the 12 questions allow us to extract recommendations and algorithms for the pharmacological treatment of tobacco dependence.

The impact of smoking on periodontal status and dental caries

INTRODUCTION

Investigations to explore the relationship between smoking and its oral manifestations are important to clinicians. Among these oral manifestations, periodontal diseases and dental caries have still a controversial association. This study aims to analyze the effect of smoking on periodontal disease and caries and their relevance to each other.

METHODS

Data on demographic and clinical features were retrieved from 7028 patients. Smoking status was categorized as a smoker, non-smoker, former smoker and passive smoker. Each patient received a diagnosis according to the new classification system for periodontal disease, in which periodontal disease is divides into stages (PS). The carries status was diagnosed by evaluating the decayed, missing, and filled teeth (DMFT) index.

RESULTS

Of the patients, 66.6% were non-smoker women, whereas 53.7 % of passive smokers were women. Being a worker and having a Bachelor’s degree was associated with a higher likelihood of getting diagnosed with periodontal disease and caries in smokers. Smoking significantly influences periodontal disease severity and DMFT values (p<0.001). This becomes more evident in former smokers by showing the highest severe periodontal problems (PS3: 29.7% and PS4: 18.9%), and the highest DMFT mean (16.4 ± 7.4) Accordingly, persons having high DMFT had significantly the most severe periodontal disease, namely PS4 (p<0.05).

CONCLUSIONS

Smoking is associated with higher caries prevalence and more severe periodontal disease, and DMFT tend to increase with the severity of periodontitis in the same subjects.

Exploring Multilevel Workplace Tobacco Control Interventions: A Scoping Review

BACKGROUND

The workplace provides a unique opportunity to intervene on tobacco use, by implementing multilevel interventions engaging diverse employees. Using the social ecological model (SEM), this scoping review aimed to synthesize descriptions of multilevel workplace tobacco control programs to create a health equity informed framework for intervention planning.

METHODS

Multiple databases were searched for articles published from January 2010 to December 2020 meeting inclusion criteria (i.e., discussed multilevel tobacco cessation interventions that intervene, target, or incorporate two or more levels of influence, and one of the levels must be the workplace). Articles were screened by two independent researchers and included if they discussed multilevel tobacco cessation interventions that intervened, targeted, or incorporated two or more levels of influence. To integrate the extracted information into the SEM, we utilized the McLeroy et al. model and definitions to describe potential multilevel interventions and their determinants.

RESULTS

Nine articles were included in this review. No studies intervened across all five levels (individual, interpersonal, institutional, community, and policy), and the most common levels of intervention were individual (e.g., individual counseling), interpersonal (e.g., group therapy), and institutional (e.g., interventions during work hours). Participation rates varied by key social determinants of health (SDOHs) such as age, gender, education and income. Barriers including cost and sustainability influenced successful implementation, while leadership endorsement and accessibility facilitated successful implementation.

DISCUSSION/APPLICATION TO PRACTICE

Multilevel interventions targeting at least two SEM levels may reduce persistent health inequities if they address how SDOHs influence individual health behaviors. Employee characteristics impacted the success of tobacco cessation interventions, but more research is needed to understand the barriers and facilitators related to workplace characteristics.

Do financial incentives increase mental health treatment engagement? A meta-analysis

OBJECTIVE

Engagement in mental health treatment is low, which can lead to poor outcomes. We evaluated the efficacy of offering patients financial incentives to increase their mental health treatment engagement, also referred to as contingency management.

METHOD

We meta-analyzed studies offering financial incentives for mental health treatment engagement, including increasing treatment attendance, medication adherence, and treatment goal completion. Analyses were run within a multilevel framework. All study designs were included, and sensitivity analyses were run including only randomized and high-quality studies.

RESULTS

About 80% of interventions incentivized treatment for substance use disorders. Financial incentives significantly increased treatment attendance (Hedges' g = 0.49, [0.33, 0.64], k = 30, I2 = 83.14), medication adherence (Hedges' g = 0.95, [0.47, 1.44], k = 6, I2 = 87.73), and treatment goal completion (Hedges' g = 0.61, [0.22, 0.99], k = 5, I2 = 60.55), including completing homework, signing treatment plans, and reducing problematic behavior.

CONCLUSIONS

Financial incentives increase treatment engagement with medium to large effect sizes. We provide strong evidence for their effectiveness in increasing substance use treatment engagement and preliminary evidence for their effectiveness in increasing treatment engagement for other mental health disorders. Future research should prioritize testing the efficacy of incentivizing treatment engagement for mental health disorders aside from substance use. Research must also identify ways to incentivize treatment engagement that improve functioning and long-term outcomes and address ethical and systemic barriers to implementing these interventions. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Occupational disease claims and non-occupational morbidity in a prospective cohort observation of nickel electrolysis workers

Exposure to nickel aerosol in the nickel production is associated with greater occupational risk, yet little is known how many workers will develop an occupational disease and claim compensation. The aim of this analysis was to prospectively observe a cohort of nickel electrolysis workers and quantitatively assess confirmed occupational disease claims. We observed a cohort of nickel electrolysis workers (N = 1397, median age 39, 68% males) from 2008 till 2020 in one of the largest nickel producers in the Russian High North. Cumulative incidence of confirmed occupational disease claims in seven occupational groups, including electrolysis operators, hydrometallurgists, crane operators, final product cleaners, metalworkers, electricians and 'other' was analyzed and supplemented with Cox proportional hazards regression, yielding hazard ratios (HR) with their 95% confidence intervals (CI) of occupational disease claims for each group. N patients with occupational disease claims varied from 1 in 2016 to 22 in 2009, and in total 87 patients developed one or more occupational diseases (cumulative incidence 6.2%, p < 0.001 between seven groups). Accounting for 35,527 person-years of observation in total, cleaners exhibited the greatest risk (HR 2.58 (95% CI 1.43-4.64)), also adjusted for smoking, number of non-occupational diseases and group 2 (hydrometallurgists). Smoking was independently associated with having an occupational disease claim in all groups (p < 0.001), as was the number of non-work-related diseases in six groups of seven. Despite consistent improvement in the exposure control measures in nickel production, occupational morbidity persists. More effort is needed to reduce exposure in final product cleaners.

Cost-Effectiveness of Four Financial Incentive Programs for Smoking Cessation

Rationale: A trial of four financial incentive programs, conducted at CVS Caremark, a large employer, documented their effectiveness in promoting sustained abstinence from smoking, but their cost-effectiveness is unknown, and the significant up-front cost of the incentives is a deterrent to their adoption. Objectives: To determine the cost-effectiveness of these incentives from the healthcare sector and employer perspectives. Methods: This study examines a decision model built with trial data, supplemented by data from the literature. Life-expectancy gains for quitters were projected on the basis of U.S. life tables. The two individual-oriented programs paid $800 for smoking cessation at 6 months; one required participants to deposit $150 at baseline. Payments in the two group-oriented programs varied with the group's success; again, one required participants to deposit $150. Results: Life-years, quality-adjusted life-years (QALYs), costs (2012 dollars), and cost-effectiveness ratios are described. From the healthcare sector perspective, costs ranged from $3,200 per life-year ($2,500 per QALY) for the competitive deposit program, compared with usual care, to $6,500 per life-year ($5,100 per QALY) for the individual reward program. From the employer perspective, costs ranged from $256,600 per life-year gained for the individual deposit program to $1,711,100 per life-year gained for the individual reward program; the cost per QALY ranged from $65,300 for the competitive deposit program to $128,800 for the individual reward program. Cost-effectiveness from the employer perspective improved with longer decision horizons. Including future medical costs reduced cost-effectiveness from both perspectives. Conclusions: Four financial incentive programs that paid smokers to quit are very cost-effective from the healthcare sector perspective. They are more expensive from the employer perspective but may be cost-effective for employers with longer decision horizons.

Social measures for reducing exposure to secondhand smoke in migrant workers of sugarcane harvest in the lower northern region of Thailand

INTRODUCTION

The sugarcane harvest migrant workers are an underprivileged group in Thailand and have a high risk of exposure to secondhand smoke but are potentially neglected in health promotion interventions.

METHODS

This three-phase study applied a mixed-method research approach. The data were collected from February to December 2019 from the Sukhothai province of Thailand. In Phase 1, the level of secondhand smoke exposure of the sugarcane harvest migrant workers at the worker camp was explored. The data were collected from 462 workers by questionnaires and from 24 sample participants in the group discussions about the factors leading to the exposure to secondhand smoke. Phase 2 was the provision and implementation of social measures for the health protection of migrant workers and families from exposure to secondhand smoke. In Phase 3, an evaluation of the health protection model for the migrant workers and families from secondhand smoke exposure was explored.

RESULTS

Workers aged ≤40 years had 1.9 times higher exposure to secondhand smoke than workers aged ≥41 years (OR=1.93; 95% CI: 1.24–3.01). Those who worked overtime had 1.7 times higher exposure to secondhand smoke than those who did not work overtime (OR=1.71; 95% CI: 1.10–2.66). Social measures to prevent secondhand smoke were: given a warning, no rewards for cigarettes, designated smoking area, not asking the children to buy cigarettes, stop displaying cigarettes at grocery shops, and empowering woman to go against the smoking husband in the camp and the sugarcane field when the women, children, and nonsmokers are present. After implementing the measures, there was no exposure to secondhand smoke inside the room, cooking area, and at the quad in the camp center.

CONCLUSIONS

Appropriate social measures for health protection can help to reduce exposure to secondhand smoke.

Descriptive Study of Employee Engagement With Workplace Wellness Interventions in the UK

OBJECTIVE

To explore sequential steps of employee engagement in wellness interventions and the impact of wellness interventions on employee health.

METHODS

Using previously collected survey data from 23,667 UK employees, we tabulated intervention availability, awareness, participation, and associated health improvement and compared engagement by participation and risk status.

RESULTS

Employees' awareness of wellness interventions at their workplaces was often low (mean 43.3%, range 11.6%-82.3%). Participation was highest in diet/nutrition initiatives (94.2%) and lowest in alcohol counseling and smoking cessation interventions (2.1%). Employees with health risks were less likely than lower-risk employees to report awareness, participation, and health improvements from wellness interventions addressing the relevant health concern.

CONCLUSION

Employers and policymakers should consider variation in intervention engagement as they plan and implement wellness interventions. Engaging employee populations with higher health risks requires a more targeted approach.

Active referral plus a small financial incentive upon cessation services use on smoking abstinence: a community-based, cluster-randomised controlled trial

BACKGROUND

Many smokers do not use existing free or low-cost smoking cessation services, cost-effective interventions to increase use are needed.

METHODS

We did a 2-armed cluster randomised controlled trial (cRCT) in Hong Kong, China, to evaluate the effectiveness of active referral plus a small financial incentive on abstinence. Chinese adult smokers who smoked at least 1 cigarette per day were proactively recruited from 70 community sites (clusters). Random allocation was concealed until the recruitment started. The intervention group received an offer of active referral to cessation services at baseline plus an incentive (HK$300/US$38) after using any cessation services within 3 months. The control group received general brief cessation advice. The primary outcomes were biochemically validated abstinence at 3 and 6 months. Operating costs in real-world implementation was calculated. Trial Registry: ClinicalTrials.gov NCT03565796.

FINDINGS

Between June and September 2018, 1093 participants were randomly assigned to the intervention (n=563) and control (n=530) groups. By intention-to-treat, the intervention group showed higher validated abstinence than the control group at 3 months (8.4% vs. 4.5%, risk ratio [RR] 1.88, 95% CI 1.01-3.51, P=0.046) and 6 months (7.5% vs. 4.5%, RR 1.72, 95% CI 1.01-2.93, P=0.046). Average cost per validated abstinence was lower in the intervention (US$ 421) than control (US$ 548) group.

INTERPRETATION

This cRCT has first shown that a simple, brief, and low-cost intervention with active referral plus a small monetary incentive was effective in increasing smoking abstinence and smoking cessation service use in community smokers.

FUNDING

Hong Kong Council on Smoking and Health.

Cost-effectiveness of guideline-based stepped and collaborative care versus treatment as usual for patients with depression - a cluster-randomized trial

BACKGROUND

Depression is associated with major patient burden. Its treatment requires complex and collaborative approaches. A stepped care model based on the German National Clinical Practice Guideline "Unipolar Depression" has been shown to be effective. In this study we assess the cost-effectiveness of this guideline based stepped care model versus treatment as usual in depression.

METHODS

This prospective cluster-randomized controlled trial included 737 depressive adult patients. Primary care practices were randomized to an intervention (IG) or a control group (CG). The intervention consisted of a four-level stepped care model. The CG received treatment as usual. A cost-utility analysis from the societal perspective with a time horizon of 12 months was performed. We used quality-adjusted life years (QALY) based on the EQ-5D-3L as effect measure. Resource utilization was assessed by patient questionnaires. Missing values were imputed by 'multiple imputation using chained equations' based on predictive mean matching. We calculated adjusted group differences in costs and effects as well as incremental cost-effectiveness ratios. To describe the statistical and decision uncertainty cost-effectiveness acceptability curves were constructed based on net-benefit regressions with bootstrapped standard errors (1000 replications). The complete sample and subgroups based on depression severity were considered.

RESULTS

We found no statically significant differences in costs and effects between IG and CG. The incremental total societal costs (+€5016; 95%-CI: [-€259;€10,290) and effects (+ 0.008 QALY; 95%-CI: [- 0.030; 0.046]) were higher in the IG in comparison to the CG. Significantly higher costs were found in the IG for outpatient physician services and psychiatrist services in comparison to the CG. Significantly higher total costs and productivity losses in the IG in comparison to the CG were found in the group with severe depression. Incremental cost-effectiveness ratios for the IG in comparison to the CG were unfavourable (complete sample: €627.000/QALY gained; mild depression: dominated; moderately severe depression: €645.154/QALY gained; severe depression: €2082,714/QALY gained) and the probability of cost-effectiveness of the intervention was low, except for the group with moderate depression (ICER: dominance; 70% for willingness-to-pay threshold of €50,000/QALY gained).

CONCLUSIONS

We found no evidence for cost-effectiveness of the intervention in comparison to treatment as usual.

TRIAL REGISTRATION

NCT, NCT01731717 . Registered 22 November 2012 - Retrospectively registered.

Cost-effectiveness and cost-utility analysis of a work-place smoking cessation intervention with and without financial incentives

AIMS

To perform an economic evaluation of a work-place smoking cessation group training programme with incentives compared with a training programme without incentives.

DESIGN

A trial-based cost-effectiveness analysis (CEA) and cost-utility analysis (CUA) from a societal perspective and an employer's perspective.

SETTING

Sixty-one companies in the Netherlands.

PARTICIPANTS

A total of 604 tobacco-smoking employees.

INTERVENTION AND COMPARATOR

A 7-week work-place smoking cessation group training programme. The intervention group earned gift vouchers of €350 for 12 months' continuous abstinence. The comparator group received no incentives.

MEASUREMENTS

Online questionnaires were administered to assess quality of life (EQ-5D-5 L) and resource use during the 14-month follow-up period (2-month training period plus 12-month abstinence period). For the CEA the primary outcome measure was carbon monoxide (CO)-validated continuous abstinence; for the CUA the primary outcome was quality-adjusted life years (QALY). Bootstrapping and sensitivity analyses were performed to account for uncertainty. Incremental cost-effectiveness ratio (ICER) tables were used to determine cost-effectiveness from a life-time perspective.

FINDINGS

Of the participants in the intervention group, 41.1% had quit smoking compared with 26.4% in the control group. From a societal perspective with a 14-month follow-up period, the ICER per quitter for an intervention with financial incentives compared with no incentives was €11 546. From an employer's perspective, the ICER was €5686. There was no significant difference in QALYs between the intervention and control group within the 14-month follow-up period. The intervention was dominated by the comparator in the primary analysis at a threshold of €20 000 per QALY. In the sensitivity analysis, these results were uncertain. A life-time perspective showed an ICER of €1249 (95% confidence interval = €850-2387) per QALY.

CONCLUSIONS

Financial incentives may be cost-effective in increasing quitting smoking, particularly from a life-time perspective.

Implementation of Financial Incentives for Successful Smoking Cessation in Real-Life Company Settings: A Qualitative Needs Assessment among Employers

Randomized studies have shown that financial incentives can significantly increase the effect of smoking cessation treatment in company settings. Evidence of effectiveness alone is, however, not enough to ensure that companies will offer this intervention. Knowledge about the barriers and facilitators for implementation in the workplace is needed, in order to develop an implementation strategy. We performed a qualitative needs assessment among 18 employers working in companies with relatively many employees with a low educational level, and our study revealed priority actions that aim to improve the implementation process in these types of workplaces. First, employers need training and support in how to reach their employees and convince them to take part in the group training. Second, employers need to be convinced that their non-smoking employees will not consider the incentives unfair, or they should be enabled to offer alternative incentives that are considered less unfair. Third, the cost-effectiveness of smoking cessation group trainings including financial incentives should be explained to employers. Finally, smoking cessation should become a standard part of workplace-based health policies.