A review of economic evaluations of tobacco control programs

Testing the Efficacy of a Scalable Telephone-Delivered Guided Imagery Tobacco Cessation Treatment: Protocol for a Randomized Clinical Trial

BACKGROUND

Tobacco use continues to be a leading preventable cause of death and disease in the United States, accounting for >480,000 deaths each year. Although treatments for tobacco use are effective for many, there is substantial variability in outcomes, and these approaches are not effective for all individuals seeking to quit smoking cigarettes. New, effective therapeutic approaches are needed to meet the preferences of people who want to stop smoking. Guided imagery (GI) is a mind-body technique that involves the guided visualization of specific mental images, which is enhanced with other sensory modalities and emotions. Preliminary evidence provides initial support for the use of GI as a treatment for cigarette smoking. Meta-analyses have shown that standard treatment for cigarette smoking delivered over the telephone via quitlines is effective. A telephone-based intervention that uses GI might provide another effective treatment option and increase the reach and effectiveness of quitlines.

OBJECTIVE

This study aims to test the efficacy of Be Smoke Free, a telephone-delivered GI treatment for smoking cessation.

METHODS

This multisite randomized clinical trial (RCT) will compare a novel telephone-delivered GI tobacco cessation treatment with a standard evidence-based behavioral treatment. The study will be conducted over 5 years. In phase 1, we refined protocols and procedures for the New York State and West Virginia sites for use in the RCT. During phase 2, we will conduct an RCT with 1200 participants: 600 (50%) recruited via quitlines and 600 (50%) recruited via population-based methods. Participants will be randomly assigned to either the GI condition or the behavioral condition; both treatments will be delivered by trained study coaches located at the University of Arizona. Assessments will be conducted at baseline and 3 and 6 months after enrollment by University of Arizona research staff. The primary outcome will be self-reported 30-day point prevalence abstinence 6 months after enrollment. Secondary outcomes include biochemically verified 7-day point prevalence abstinence 6 months after enrollment.

RESULTS

Recruitment in West Virginia and New York began in October 2022. As of March 31, 2023, a total of 242 participants had been enrolled. Follow-up assessments began in November 2022. As of March 31, 2023, of the 118 eligible participants, 97 (82.2%) had completed the 3-month assessment, and 93% (26/28) of eligible participants had completed the 6-month assessment. Biochemical verification and qualitative interviews began in April 2023. Recruitment will continue through 2025 and follow-up assessments through 2026. Primary results are expected to be published in 2027.

CONCLUSIONS

The Be Smoke Free study is a first-of-its-kind RCT that incorporates GI into telephone-based tobacco cessation treatment. If successful, Be Smoke Free will have substantial benefits for the long-term health of people who use tobacco across the United States.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05277831; https://clinicaltrials.gov/ct2/show/NCT05277831.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/48898.

Evaluation of the sugar-sweetened beverage tax in Oakland, United States, 2015-2019: A quasi-experimental and cost-effectiveness study

BACKGROUND

While a 2021 federal commission recommended that the United States government levy a sugar-sweetened beverage (SSB) tax to improve diabetes prevention and control efforts, evidence is limited regarding the longer-term impacts of SSB taxes on SSB purchases, health outcomes, costs, and cost-effectiveness. This study estimates the impact and cost-effectiveness of an SSB tax levied in Oakland, California.

METHODS AND FINDINGS

An SSB tax ($0.01/oz) was implemented on July 1, 2017, in Oakland. The main sample of sales data included 11,627 beverage products, 316 stores, and 172,985,767 product-store-month observations. The main analysis, a longitudinal quasi-experimental difference-in-differences approach, compared changes in beverage purchases at stores in Oakland versus Richmond, California (a nontaxed comparator in the same market area) before and 30 months after tax implementation (through December 31, 2019). Additional estimates used synthetic control methods with comparator stores in Los Angeles, California. Estimates were inputted into a closed-cohort microsimulation model to estimate quality-adjusted life years (QALYs) and societal costs (in Oakland) from 6 SSB-associated disease outcomes. In the main analysis, SSB purchases declined by 26.8% (95% CI -39.0 to -14.7, p < 0.001) in Oakland after tax implementation, compared with Richmond. There were no detectable changes in purchases of untaxed beverages or sweet snacks or purchases in border areas surrounding cities. In the synthetic control analysis, declines in SSB purchases were similar to the main analysis (-22.4%, 95% CI -41.7% to -3.0%, p = 0.04). The estimated changes in SSB purchases, when translated into declines in consumption, would be expected to accrue QALYs (94 per 10,000 residents) and significant societal cost savings (>$100,000 per 10,000 residents) over 10 years, with greater gains over a lifetime horizon. Study limitations include a lack of SSB consumption data and use of sales data primarily from chain stores.

CONCLUSIONS

An SSB tax levied in Oakland was associated with a substantial decline in volume of SSBs purchased, an association that was sustained more than 2 years after tax implementation. Our study suggests that SSB taxes are effective policy instruments for improving health and generating significant cost savings for society.

Changes in ideal cardiovascular health among Malawian adults from 2009 to 2017

Ideal Cardiovascular Health (CVH) is a concept defined by the American Heart Association (AHA) as part of its 2020 Impact Goals. Until now, changes in ideal CVH have been poorly evaluated in Sub-Saharan African populations. We aimed to investigate changes in the prevalence of ideal CVH and its components in a population of Malawian adults. Secondary analysis was done on cross-sectional data from 2009 to 2017, obtained from the Malawi STEPS surveys which included 5730 participants aged 25-64 years. CVH metrics categorized into "ideal (6-7 ideal metrics)", "intermediate (3-5 ideal metrics)" and "poor (0-2 ideal metrics)" were computed using blood pressure, body mass index (BMI), fasting glycaemia, fruit and vegetable intake, physical activity, smoking, and total cholesterol. Sampling weights were used to account for the sampling design, and all estimates were standardised by age and sex using the direct method. The mean participant age across both periods was 40.1 ± 12.4 years. The prevalence of meeting ≥ 6 ideal CVH metrics increased substantially from 9.4% in 2009 to 33.3% in 2017, whereas having ≤ 2 ideal CVH metrics decreased from 7.6% to 0.5% over this time. For the individual metrics, desirable levels of smoking, fruit and vegetable intake, physical activity, blood pressure (BP), total cholesterol and fasting glucose all increased during the study period whilst achievable levels of BMI (< 25 kg/m²) declined. From 2009 to 2017, the mean number of ideal CVH metrics was higher in women compared to men (from 2.1% to 5.1% vs 2.0% to 5.0%). However, poor levels of smoking and fruit and vegetable intake were higher in men compared to women (from 27.9% to 23.6% vs. 7.4%% to 1.9% , and from 33.7% to 42.9% vs 30.8% to 34.6%, respectively). Also, whilst achievable levels of BMI rose in men (from 84.4% to 86.2%) the proportion reduced in women (from 72.1% to 67.5% ). Overall, CVH improved in Malawian adults from 2009 to 2017 and was highest in women. However, the prevalence of poor fruit and vegetable intake, and poor smoking remained high in men whilst optimal levels of BMI was declined in women. To improve this situation, individual and population-based strategies that address body mass, smoking and fruit and vegetable intake are warranted for maximal health gains in stemming the development of cardiovascular events.

Brazilian Survey on Preventive Actions for the Population With Access to Primary Healthcare: Inefficient Spending in a Country in Economic Crisis

BACKGROUND

Cancer ranks second as a cause of death in Brazil. Although preventive practices are part of the daily routine of primary healthcare (PHC) teams, organized screening programs are lacking. This study aimed to evaluate the adequacy of preventive interventions in the main cancer types, as defined by the Brazilian government.

METHODS

We analyzed cross-sectional data from a larger project conducted in 2016 with PHC service users and physicians from all over Brazil, interviewed by trained research staff. The sample was stratified by the number of PHC physicians per geographic region, who were eligible for inclusion if they had been working in the same PHC unit for at least one year. Twelve adult patients with at least two encounters were included per participating physician. Only the data from service users were analyzed in this study. We evaluated the questions about preventive practices and calculated the following indicators: coverage, focus, screening errors, and screening ratio. National guidelines and international evidence were used as a comparison parameter.

RESULTS

The study population consisted of 6160 service users. The data indicate that the recommendations for cervical, breast, and prostate cancer screening and for treatment of tobacco dependence are not adequately followed. Coverage for breast and cervical cancer screening presented an overutilization bias, with rates 50% and 9% above the expected, respectively. The screening focus was also inadequate: 24%, 47%, and 54% of the screening tests for the three cancer types were performed in individuals outside the recommended age range. 31% of smokers were not approached for treatment.

CONCLUSION

These findings indicate that the Brazilian population has been subjected to inadequate and potentially iatrogenic interventions in PHC. New policies based on stricter criteria of adequacy and increased use of the concept of quaternary prevention may improve the effectiveness and equity of the health system.

Treatment use patterns in a large extended-treatment tobacco cessation program: predictors and cost implications

BACKGROUND

Tobacco dependence follows a chronic and relapsing course, but most treatment programmes are short. Extended care has been shown to improve outcomes. Examining use patterns for longer term programmes can quantify resource requirements and identify opportunities for improving retention.

METHODS

We analyse 38 094 primary care treatment episodes from a multisite smoking cessation programme in Ontario, Canada that provides free nicotine replacement therapy (NRT) and counselling. We calculate distributional measures of weeks of NRT used, clinical visits attended and total length of care. We then divide treatment courses into four exclusive categories and fit a multinomial logistic regression model to measure associations with participant characteristics, using multiple imputation to address missing data.

RESULTS

Time in treatment (median=50 days), visits (median=3) and weeks NRT used (median=8) were well below the maximum available. Of all programme enrolments, 28.8% (95% CI=28.3% to 29.3%) were single contacts, 31.3% (30.8% to 31.8%) lasted <12 weeks, 19.2% (18.8% to 19.6%) were ≥12 weeks with an 8-week interruption and 20.7% (20.3%-21.1%) were ≥12 weeks without interruptions. Care use was most strongly associated with participant age and whether the nicotine patch was dispensed at the first visit.

CONCLUSION

Treatment use results imply that the marginal costs of extending treatment programmes are relatively low. The prevalence of single contacts supports additional engagement efforts at the initial visit, while interruptions in care highlight the ability of longer term care to address relapse. Results show that use of the nicotine patch is associated with retention in care, and that improving engagement of younger patients should be a priority.

Smoking Cessation therapy is a cost-effective intervention to avoid tooth loss in Brazilian subjects with periodontitis: an economic evaluation

Background

Smokers present a higher prevalence and severity of periodontitis and, consequently, higher prevalence of tooth loss. Smoking cessation improves the response to periodontal treatment and reduces tooth loss. So, the aim of this study was to evaluate the efficiency in resources allocation when implementing smoking cessation therapy vs. its non-implementation in smokers with periodontitis.

Methods

We adopted the Brazilian public system perspective to determine the incremental cost-effectiveness (cost per tooth loss avoided) and cost-utility (cost per oral-related quality-adjusted life-year ([QALY] gained) of implementing smoking cessation therapy. Base-case was defined as a 48 years-old male subject and horizon of 30 years. Effects and costs were combined in a decision analytic modeling framework to permit a quantitative approach aiming to estimate the value of the consequences of smoking cessation therapy adjusted for their probability of occurrence. Markov models were carried over annual cycles. Sensitivity analysis tested methodological assumptions.

Results

Implementing the therapy saved approximately US$ 100 over the time horizon accompanied by a slightly better effect, both in CEA and CUA. Considering uncertainties, the therapy could be cost-effective in the most part of simulated cases, even being cheaper and more effective in 35% of cases in which the oral-health related outcome is used as effect. Considering a willingness-to-pay of US$100 per health effect, smoking cessation therapy was cost-effective, respectively, in 72% and 99% of cases in cost-utility and cost-effectiveness analyses.

Conclusions

Implementation of smoking cessation therapy may be cost-effective, considering the avoidance of tooth loss and oral health-related consequences to patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-021-01932-2.

Effectiveness of anti-smoking interventions towards community: a meta-analysis study

OBJECTIVES

Smoking is one of the biggest public health problems in the world. The World Health Organization (WHO) has declared the MPOWER package which provides a guide for tobacco control. The package includes six evidence based anti-smoking interventions. This meta-analysis study aims to assess the effectiveness of MPOWER - (M)onitor, (P)rotect, (O)ffer, (W)arn, (E)nforce, and (R)aise. In the study, "smoking prevalence rate, smoking cessation rate and number of cigarettes smoked daily" outputs were used in adult and adolescent age groups.

METHODS

Literature search has been made with "smok*, tobacco, cigarette*" keywords from the databases of Medline, Web of Science, Scopus, and Cochrane-Library. Abstracts were assessed in detail according to the inclusion criteria by the research team. Quality of articles was evaluated with modified Jadad criteria. The follow-up periods of articles were determined in two groups named as short and long term periods. We used random effects model (p ≤ 0.05) and fixed effects model (p > 0.05) according to the heterogeneity test results.

RESULTS

P and O interventions, which are evaluated with smoking cessation rate, increased the smoking cessation rate in adults by 39% in the longest follow-up period - RR: 1.39 (1.23-1.57). However, it was determined that the interventions were not effective on smoking cessation rate in adolescents - RR: 1.13 (0.90-1.42). Nicotine replacement therapy (NRT) was the most effective intervention for smoking cessation rate in adults. W interventions, which are evaluated with smoking prevalence rate, decreased the smoking prevalence rate in adults by 13% in the longest follow-up period - OR: 0.87 (0.82-0.92). P, W and E interventions, which are evaluated with smoking prevalence rate, decreased the smoking prevalence rate in adolescents by 26% in the longest follow-up period - OR: 0.74 (0.68-0.80).

CONCLUSIONS

MPOWER interventions affect smoking prevalence rate, smoking cessation rate and number of cigarettes smoked daily in different age groups. Well-controlled, well-planned and cost-effective anti-smoking interventions have great importance for public health protection.

Economic analyses of mental health and substance use interventions in the workplace: a systematic literature review and narrative synthesis

Mental illness and substance use disorders in the workplace have been increasingly recognised as a problem in most countries; however, evidence is scarce on which solutions provide the highest return on investment. We searched academic and grey literature databases and additional sources for studies that included a workplace intervention for mental health or substance abuse, or both, and that did an economic analysis. We analysed the papers we found to identify the highest yielding and most cost-effective interventions by disorder. On the basis of 56 studies, we found moderate strength of evidence that cognitive behavioural therapy is cost-saving (and in some cases cost-effective) to address depression. We observed strong evidence that regular and active involvement of occupational health professionals is cost-saving and cost-effective in reducing sick leave related to mental health and in encouraging return to work. We identified moderate evidence that coverage for pharmacotherapy and brief counselling for smoking cessation are both cost-saving and cost-effective. Addressing mental health and substance misuse in the workplace improves workers' wellbeing and productivity, and benefits employers' bottom line (ie, profit). Future economic analyses would benefit from the consideration of subgroup analyses, examination of longer follow-ups, inclusion of statistical and sensitivity analyses and discussion around uncertainty, and consideration of potential for bias.

Economic evaluation in the National Drug Abuse Treatment Clinical Trials Network: Past, present, and future

Economic evaluations provide evidence that informs stakeholders on how to efficiently allocate real and financial healthcare resources. The purpose of this study was to review and discuss the integration of economic evaluations into the National Drug Abuse Treatment Clinical Trials Network (CTN) since its inception, as well as expectations for the future of this relationship. A systematic review was performed on published and planned CTN economic evaluations in the CTN dissemination library and PubMed. The well-established Drummond checklist was used to evaluate the comprehensiveness and methodological rigor of published articles. One hundred thirty-eight ancillary, follow-up, or original protocols were reviewed, and 78 potentially relevant published articles were identified. A total number of 14 protocols included an economic evaluation. Of these, 6 protocols were completed, 2 were reported as active, and 6 were reported as in-development at the time of this review. Of the 78 published articles, 9 met the inclusion criteria. As gauged by the Drummond checklist, the quality of CTN published economic evaluations were found to improve over time, and recent published articles were identified as guides to cutting-edge economic research. As the CTN continues to grow and mature, it is imperative that high-quality economic evaluations are incorporated alongside trials in order to maximize the public health impact of the CTN.

Cost-effectiveness of e-cigarettes compared with nicotine replacement therapy in stop smoking services in England (TEC study): a randomized controlled trial

AIM

To evaluate the cost-effectiveness of e-cigarettes as a smoking cessation aid used in routine stop smoking services in England.

DESIGN

Cost-effectiveness analysis was performed from the National Health Service (NHS) and Personal Social Services (PSS) perspective for 12-month periods and life-time. Costs, including that of both treatments, other smoking cessation help and health-care services, and health benefits, estimated from EQ-5D-5L and measured in quality-adjusted life-years (QALYs), for the 12-month analysis, came from a randomized controlled trial. Life-time analysis was model-based with input from both trial data and published secondary data sources. Cost-effectiveness was measured by an incremental cost-effectiveness ratio (ICER).

SETTING

Three stop-smoking service sites in England.

PARTICIPANTS

Adult smokers (n = 886) who sought help to quit in the participating sites.

INTERVENTION AND COMPARATOR

An e-cigarette (EC) starter kit versus provision of nicotine replacement therapy (NRT) for up to 3 months, both with standard behavioural support. A total of 886 participants were randomized (439 in the EC arm, 447 in the NRT arm). Excluding one death in each arm, the 1-year quit rate was 18.0 and 9.9%, respectively.

MEASUREMENTS

Cost of treatments was estimated from the treatment log. Costs of other smoking cessation help and health-care services and EQ-5D-5 L were collected at baseline, 6- and 12-month follow-ups. Incremental costs and incremental QALYs were estimated using regression adjusting for baseline covariates and their respective baseline values.

FINDINGS

The ICER was £1100 per QALY gained at the 12 months after quit date (87% probability below £20 000/QALY). Markov model estimated the life-time ICER of EC to be £65 per QALY (85% probability below £20 000/QALY).

CONCLUSION

Using e-cigarettes as a smoking cessation aid with standard behavioural support in stop-smoking services in England is likely to be more cost-effective than using nicotine replacement therapy in the same setting.

Text2Connect: a health system approach to engage tobacco users in quitline cessation services via text messaging

Mobile technology has created the opportunity for health systems to provide low cost tobacco cessation assistance to patients. The goal of the present study was to examine the feasibility and effectiveness of an intervention (Text2Connect) that uses text messages to offer proactive connection to the New York State Smokers' Quitline. The electronic health record at two urban health systems was queried for patients who were current smokers and who had an outpatient visit between March 2015 and February 2016. Smokers (N = 4000) were sent an informational letter. Those who did not opt out (N = 3719) were randomized to one of 6 message sequences in order to examine the effect of theoretically informed message frames on response rates. Participants were sent a series of text messages at baseline and at 1 month and were asked to reply in order to be contacted by the state quitline (QL). After removing 1403 nonworking numbers, texts were sent to 2316 patients, and 10.0% (205/2060) responded with a QL request. Almost one quarter (23.6%, 486/2060) replied STOP and 66.4% (1369/2060) never responded. QL request rates were significantly higher when response efficacy messages were not used (p < .001). There were no differences by message framing on STOP requests (p > .05). The Text2Connect intervention was well accepted with a minority opting out. A 10% QL response rate is noteworthy given that only 5-7 brief outreach text messages were used. Results indicate that simple self-efficacy-focused messaging is most effective at supporting response rates.

State Tobacco Policies as Predictors of Evidence-Based Cessation Method Usage: Results From a Large, Nationally Representative Dataset

Introduction

Evidence-based cessation methods including nicotine replacement therapy (NRT), non-NRT medications, quitlines, and behavioral treatments are underutilized by smokers attempting to quit. Although a number of studies have demonstrated a relationship between state-level tobacco policies (eg, taxation, appropriations) and cessation, whether such state-level factors influence likelihood of using an evidence-based treatment is unclear. Accordingly, the aims of the present study were: (1) to describe evidence-based cessation method utilization by state and (2) to examine the effect of state-level factors on cessation method utilization above and beyond individual-level predictors.

Methods

Data were utilized from the 2010-2011 Tobacco Use Supplement to the Current Population Survey (TUS-CPS). Participants included 9232 smokers who reported a past-year quit attempt. Data on 11 state-level predictors were collated from national datasets. Analyses were based on: (1) descriptive characterization of quit method usage, (2) logistic regression models to determine state-level factors as predictors of quit method utilization, controlling for individual-level predictors, (3) cluster analyses grouping states with similar state-level factors, and (4) examination of cluster as a predictor of cessation method.

Results

Tobacco control appropriations significantly predicted NRT, quitline, and behavioral treatment utilization. Additional state-level factors that demonstrated significant relationships included Medicaid coverage of non-NRT medications and behavioral treatment, tobacco tax rate, smoking prevalence, and percentage of population uninsured. State clustering significantly predicted quit method across all four methods.

Conclusions

State-level factors influence the likelihood of residents utilizing evidence-based quit methods. Results are discussed in terms of implications for tobacco policy at the state level.

Implications

Results from the present study highlight state tobacco control appropriations as a robust predictor of evidence-based cessation method utilization. Other significant state-level predictors of evidence-based cessation method utilization included Medicaid coverage of non-NRT medications and behavioral treatment, tobacco tax rate, smoking prevalence, and percentage of population uninsured. Moreover, state-level predictors clustered together to significantly predict evidence-based cessation method utilization. Thus, increasing tobacco control appropriations, extending health insurance coverage, maximizing revenue from tobacco taxation and tobacco settlements, and ultimately decreasing smoking prevalence are important targets for individual states to promote utilization of evidence-based cessation methods.

Testing the feasibility of a guided imagery tobacco cessation intervention delivered by a telephone quitline: Study protocol for a randomized controlled feasibility trial

Background

Guided imagery (GI) is an evidence-based method that uses the imagination to practice and achieve a desired outcome. Little research has focused on how GI can be delivered to smokers using remote or virtual methods, such as a telephone-based intervention. Telephone-based services for tobacco cessation (quitlines) have emerged as standard of care for tobacco cessation. However, quitlines reach only a small fraction of smokers, and men and racial/ethnic minorities are less likely to use quitlines than majority women. GI has the potential to attract under-served minority groups as well as smokers who are looking for an alternative approach to cessation. The present study is designed to test the feasibility and potential impact of a GI tobacco cessation intervention delivered by telephone. This study compares the GI intervention with a standard behavioral (SB) intervention.

Methods

Participants (N = 100) are randomized to either the GI (intervention) or SB (control) condition. Each condition features a 6-week intervention in which participants work with coaches to quit tobacco. Primary outcomes are feasibility related (recruitment, retention, adherence), and secondary outcomes include cessation at 6 months post-intervention (7-day and 30-day abstinence).

Discussion

A GI intervention delivered via quitline would allow for scalability and dissemination, potentially reaching a more representative group of smokers. Results from this study will determine the feasibility of delivering the GI intervention, and describe the reach of the intervention to under-represented tobacco users. If successful, our study results will guide the design and conduct of a future efficacy trial.

Fixed night workers and failed smoking cessation

Background

The objective of this study was to examine the relationship between employee work schedule and failure in smoking cessation.

Methods

Logistic regression was used to estimate the association between work schedule and failed smoking cessation rate among 4927 male workers who had attempted smoking cessation. The data was obtained from the annual Korean National Health and Nutrition Examination Survey from 2007 to 2015 (excluding data from 2013). An adjusted model, including demographic and occupational variables, was constructed after stratifying the data into two subgroups by age (the 19- to 40-year-old group and the 41- to 60-year-old group).

Results

The percentage of smoking-cessation failure varied according to work schedule and age. The failure rate in the 19- to 40-year-old group was generally higher for all work schedule categories than in the 41- to 60-year-old group. In particular, the highest percentage (90.9%) of smoking-cessation failure was in the fixed overnight work group. After adjusting for demographic characteristics and work organization variables, the odds ratio for failed smoking cessation across all ages was 3.30 (95%CI 2.23–4.86) among the fixed overnight workers compared to the daytime workers. Both of the age-stratified subgroups maintained this relationship, with a notably higher OR in the 19- to 40-year-old group (OR 3.74, 95% CI 1.80–7.77).

Conclusions

Fixed overnight work is likely to negatively affect smoking cessation compared to other work schedules. Tailored anti-smoking intervention programs are required based on work schedule.

Mass media to communicate public health messages in six health topic areas: a systematic review and other reviews of the evidence

Background

Mass media campaigns can be used to communicate public health messages at the population level. Although previous research has shown that they can influence health behaviours in some contexts, there have been few attempts to synthesise evidence across multiple health behaviours.

Objectives

To (1) review evidence on the effective use of mass media in six health topic areas (alcohol, diet, illicit drugs, physical activity, sexual and reproductive health and tobacco), (2) examine whether or not effectiveness varies with different target populations, (3) identify characteristics of mass media campaigns associated with effectiveness and (4) identify key research gaps.

Design

The study comprised (1) a systematic review of reviews, (2) a review of primary studies examining alcohol mass media campaigns, (3) a review of cost-effectiveness evidence and (4) a review of recent primary studies of mass media campaigns conducted in the UK. A logic model was developed to inform the reviews. Public engagement activities were conducted with policy, practitioner and academic stakeholders and with young people.

Results

The amount and strength of evidence varies across the six topics, and there was little evidence regarding diet campaigns. There was moderate evidence that mass media campaigns can reduce sedentary behaviour and influence sexual health-related behaviours and treatment-seeking behaviours (e.g. use of smoking quitlines and sexual health services). The impact on tobacco use and physical activity was mixed, there was limited evidence of impact on alcohol use and there was no impact on illicit drug behaviours. Mass media campaigns were found to increase knowledge and awareness across several topics, and to influence intentions regarding physical activity and smoking. Tobacco and illicit drug campaigns appeared to be more effective for young people and children but there was no or inconsistent evidence regarding effectiveness by sex, ethnicity or socioeconomic status. There was moderate evidence that tobacco mass media campaigns are cost-effective, but there was weak or limited evidence in other topic areas. Although there was limited evidence on characteristics associated with effectiveness, longer or greater intensity campaigns were found to be more effective, and messages were important, with positive and negative messages and social norms messages affecting smoking behaviour. The evidence suggested that targeting messages to target audiences can be effective. There was little evidence regarding the role that theory or media channels may play in campaign effectiveness, and also limited evidence on new media.

Limitations

Statistical synthesis was not possible owing to considerable heterogeneity across reviews and studies. The focus on review-level evidence limited our ability to examine intervention characteristics in detail.

Conclusions

Overall, the evidence is mixed but suggests that (1) campaigns can reduce sedentary behaviour, improve sexual health and contribute to smoking cessation, (2) tobacco control campaigns can be cost-effective, (3) longer and more intensive campaigns are likely to be more effective and (4) message design and targeting campaigns to particular population groups can be effective.

Future work

Future work could fill evidence gaps regarding diet mass media campaigns and new-media campaigns, examine cost-effectiveness in areas other than tobacco and explore the specific contribution of mass media campaigns to multicomponent interventions and how local, regional and national campaigns can work together.

Study registration

This study is registered as PROSPERO CRD42015029205 and PROSPERO CRD42017054999.

Funding

The National Institute for Health Research Public Health Research programme.

Exposures to the tobacco retail environment among adolescent boys in urban and rural environments

BACKGROUND

The tobacco industry spends billions on retail marketing and such marketing is associated with tobacco use. Previous research has not examined actual and potential exposures that adolescents have on a daily basis.

OBJECTIVE

The objective of this study was to determine whether both self-reported and geographically estimated tobacco retailer exposures differ by participant or neighborhood characteristics among urban and rural adolescents.

METHODS

The data for this study were part of a cohort study of 1220 adolescent males residing in urban and rural (Appalachian) regions in Ohio. The baseline survey asked participants how often they visited stores that typically sell tobacco in the past week (self-reported exposures). The number of tobacco retailers between home and school was determined using ArcGIS software (potential exposures). Adjusted regression models were fit to determine the characteristics that were associated with self-reported or potential exposures to retailers.

RESULTS

Adolescents who were non-Hispanic black or other racial/ethnic minority, had used tobacco in the past, and lived in rural areas had higher self-reported exposures. Urban adolescents, non-Hispanic black or other racial/ethnic minority, and those living in neighborhoods with a higher percentage of poverty had more potential exposures to tobacco retailers in their path between home and school.

CONCLUSIONS

Rural adolescents had more self-reported marketing exposures than urban adolescents. However, urban adolescents had more potential tobacco exposures between home and school. Thus, point of sale marketing limitations might be a more effective policy intervention in rural areas whereas limits on tobacco retailers might be more effective for urban areas.

The evidence-and acceptability-of taxes on unhealthy foods

The global obesity pandemic has public advocates and policymakers grappling with the question of how best to respond. Among the various policy options, unhealthy food and beverage taxes have gained attention as a potentially effective intervention to reduce non-nutritive caloric intake, while raising government funds for health promotion programs at the community level. Yet in many countries, including in Israel, such proposals have not gained broad support. Cities in both United States and Mexico have found that taxes on sugar-sweetened beverages reduce consumption. Yet the food industry has successfully fought many such policies. Looking forward, those supporting taxation policies will need to provide clear evidence, a compelling use of funds raised, a convincing answer to industry claims, and attention to equity in implementation. With no easy fixes in sight to obesity, it is likely that taxes will remain viable – if contested – options for the foreseeable future.

Economic evaluation of smoking cessation in Ontario's regional cancer programs

Quitting smoking after a diagnosis of cancer results in greater response to treatment and decreased risk of disease recurrence and second primary cancers. The objective of this study was to evaluate the potential cost-effectiveness of two smoking cessation approaches: the current basic smoking cessation program consisting of screening for tobacco use, advice, and referral; and a best practice smoking cessation program that includes the current basic program with the addition of pharmacological therapy, counseling, and follow-up. A Markov model was constructed that followed 65-year-old smokers with cancer over a lifetime horizon. Transition probabilities and mortality estimates were obtained from the published literature. Costs were obtained from standard costing sources in Ontario and reports. Probabilistic and deterministic sensitivity analyses were conducted to address parameter uncertainties. For smokers with cancer, the best practice smoking cessation program was more effective and more costly than the basic smoking cessation program. The incremental cost-effectiveness ratio of the best practice smoking cessation program compared to the basic smoking cessation program was $3367 per QALY gained and $5050 per LY gained for males, and $2050 per QALY gained and $4100 per LY gained for females. Results were most sensitive to the hazard ratio of mortality for former and current smokers, the probability of quitting smoking through participation in the program and smoking-attributable costs. The study results suggested that a best practice smoking cessation program could be a cost-effective option. These findings can support and guide implementation of smoking cessation programs.

Primary and secondary prevention interventions for cardiovascular disease in low-income and middle-income countries: a systematic review of economic evaluations

Background

Cardiovascular disease (CVD) is the leading cause of deaths globally, with greatest premature mortality in the low- and middle-income countries (LMIC). Many of these countries, especially in sub-Saharan Africa, have significant budget constraints. The need for current evidence on which interventions offer good value for money to stem this CVD epidemic motivates this study.

Methods

In this systematic review, we included studies reporting full economic evaluations of individual and population-based interventions (pharmacologic and non-pharmacologic), for primary and secondary prevention of CVD among adults in LMIC. Several medical (PubMed, EMBASE, SCOPUS, Web of Science) and economic (EconLit, NHS EED) databases and grey literature were searched. Screening of studies and data extraction was done independently by two reviewers. Drummond’s checklist and the National Institute for Health and Care Excellence quality rating scale were used in the quality appraisal for all studies used to inform this evidence synthesis.

Results

From a pool of 4059 records, 94 full texts were read and 50 studies, which met our inclusion criteria, were retained for our narrative synthesis. Most of the studies were from middle-income countries and predominantly of high quality. The majority were modelled evaluations, and there was significant heterogeneity in methods. Primary prevention studies dominated secondary prevention. Most of the economic evaluations were performed for pharmacological interventions focusing on blood pressure, cholesterol lowering and antiplatelet aggregants. The greatest majority were cost-effective. Compared to individual-based interventions, population-based interventions were few and mostly targeted reduction in sodium intake and tobacco control strategies. These were very cost-effective with many being cost-saving.

Conclusions

This evidence synthesis provides a contemporary update on interventions that offer good value for money in LMICs. Population-based interventions especially those targeting reduction in salt intake and tobacco control are very cost-effective in LMICs with potential to generate economic gains that can be reinvested to improve health and/or other sectors. While this evidence is relevant for policy across these regions, decision makers should additionally take into account other multi-sectoral perspectives, including considerations in budget impact, fairness, affordability and implementation while setting priorities for resource allocation.

Electronic supplementary material

The online version of this article (10.1186/s12962-018-0108-9) contains supplementary material, which is available to authorized users.

Smoking, health-related quality of life and economic evaluation

BACKGROUND AND AIMS

The economic evaluation of tobacco control policies requires the adoption of assumptions about the impact of changes in smoking status on health-related quality of life (HRQoL). Estimates for such impacts are necessary for different populations. This paper aims to test whether smoking status has an independent effect on HRQoL over and above the effect derived from the increased likelihood of suffering a tobacco related disease, and to calculate utility values for the Spanish population.

METHODS

Using data from the Spanish Encuesta Nacional de Salud of 2011-12, we estimate statistical models for HRQoL as measured by the EQ-5D-5L instrument as a function of smoking status. We include a comprehensive set of controls for biological, clinical, lifestyle and socioeconomic characteristics.

RESULTS

Smoking status has an independent, statistically significant effect on HRQoL. However, the size of the effect is small. The typical smoking related diseases, such as lung cancer, are associated with a reduction in HRQoL about 5 times larger than the difference between current smokers and never smokers.

CONCLUSION

Attributing substantive HRQoL gains to quitting smoking as well as accounting for the concomitant HRQoL gain derived from a smaller likelihood of contracting tobacco related diseases might lead to an overestimation of the benefits of tobacco control policies. Nonetheless, the relatively large drops in HRQoL associated with being diagnosed with diseases that might be causally linked to tobacco suggest that such diseases should not be omitted from the economic evaluations of tobacco control policies.

The case of national health promotion policy in Australia: where to now?

Issue addressed Over the last three decades there has been an incremental investment in health promotion and prevention across Australia; yet, the Commonwealth Government and some state/territory governments have more recently instigated funding cuts in health promotion and prevention. This paper argues that the role of health promotion is critical in contemporary Australia and discusses strategies needed to move forward within the context of recent disinvestments. Discussion Key areas of concern relating to recent health promotion and prevention disinvestment in Australia include the abolishment of the Australian National Preventive Health Agency, the cessation of the National Partnership Agreement on Preventive Health and significant cuts to Indigenous programs. These changes pose a significant threat to the health, economic and social well being of Australians and the region, particularly those that are most vulnerable. Conclusions Future health promotion and prevention efforts will require strategic leadership and action to enhance the promotion of health equity in Australia over the coming decades. We call on governments to (re)invest in health promotion and prevention both in and outside the health sector so that health promotion professionals can continue their advocacy efforts aimed at articulating their professional place in improving population health. So what? Recent changes to national health promotion and prevention policy are detrimental to the health and well being of the Australian population, particularly those most vulnerable. Sound planning to revitalise and refocus health promotion action in Australia is urgently required.

Seven years of progress in tobacco control: an evaluation of the effect of nations meeting the highest level MPOWER measures between 2007 and 2014

OBJECTIVE

Since WHO released the package of six MPOWER measures to assist nations with implementing the WHO Framework Convention for Tobacco Control (FCTC), 88 countries adopted at least one highest level MPOWER measure. We estimated the subsequent reduction in smoking-related deaths from all new highest level measures adopted between 2007 and 2014.

METHODS

Policy effect sizes based on previously validated SimSmoke models were applied to the number of smokers in each nation to determine the reduction in the number of smokers from policy adoption. On the basis of research that half of all smokers die from smoking, we derived the smoking-attributable deaths (SADs) averted of those smokers alive today.

FINDINGS

In total, 88 countries adopted at least one highest level MPOWER policy between 2007 and 2014, resulting in almost 22 million fewer projected SADs. The largest number of future SADs averted was due to increased cigarette taxes (7.0 million), followed by comprehensive smoke-free laws (5.4 million), large graphic health warnings (4.1 million), comprehensive marketing bans (3.8 million) and comprehensive cessation interventions (1.5 million).

CONCLUSIONS

These findings demonstrate the immense public health impact of tobacco control policies adopted globally since the WHO-FCTC and highlight the importance of more countries adopting highest level MPOWER measures to reduce the global burden of tobacco use. Substantial additional progress could be made, especially if heavily populated nations with high smoking prevalence were to reach highest level MPOWER measures.

Costs of the Smoking Cessation Program in Brazil

OBJECTIVE

To assess the costs of the Smoking Cessation Program in the Brazilian Unified Health System and estimate the cost of its full implementation in a Brazilian municipality.

METHODS

The intensive behavioral therapy and treatment for smoking cessation includes consultations, cognitive-behavioral group therapy sessions, and use of medicines. The costs of care and management of the program were estimated using micro-costing methods. The full implementation of the program in the municipality of Goiania, Goias was set as its expansion to meet the demand of all smokers motivated to quit in the municipality that would seek care at Brazilian Unified Health System. We considered direct medical and non-medical costs: human resources, medicines, consumables, general expenses, transport, travels, events, and capital costs. We included costs of federal, state, and municipal levels. The perspective of the analysis was that from the Brazilian Unified Health System. Sensitivity analysis was performed by varying parameters concerning the amount of activities and resources used. Data sources included a sample of primary care health units, municipal and state secretariats of health, and the Brazilian Ministry of Health. The costs were estimated in Brazilian Real (R$) for the year of 2010.

RESULTS

The cost of the program in Goiania was R$429,079, with 78.0% regarding behavioral therapy and treatment of smoking. The cost per patient was R$534, and, per quitter, R$1,435. The full implementation of the program in the municipality of Goiania would generate a cost of R$20.28 million to attend 35,323 smokers.

CONCLUSIONS

The Smoking Cessation Program has good performance in terms of cost per patient that quit smoking. In view of the burden of smoking in Brazil, the treatment for smoking cessation must be considered as a priority in allocating health resources.

OBJETIVO

Analisar os custos do Programa de Tratamento do Tabagismo no Sistema Único de Saúde e estimar o custo de sua implementação plena em um município brasileiro.

MÉTODOS

A abordagem intensiva e tratamento do tabagismo engloba consultas, sessões de terapia cognitivo-comportamental em grupo e uso de medicamentos. Os custos do atendimento e gerenciamento do programa foram estimados utilizando a metodologia do microcusteio. A implementação plena do programa no município de Goiânia, Goiás, foi definida como sua expansão para suprir a demanda de todos os fumantes motivados a parar de fumar no município que seriam atendidos pelo Sistema Único de Saúde. Foram considerados custos médicos e não médicos diretos: recursos humanos, medicamentos, material de consumo, despesas gerais, transporte, viagens, eventos e custos de capital. Foram incluídos custos dos níveis federal, estadual e municipal de gestão. A perspectiva da análise foi a do Sistema Único de Saúde. Análise de sensibilidade foi realizada variando parâmetros referentes à quantidade de atividades e aos recursos utilizados. As fontes de dados incluíram uma amostra de unidades de saúde da Atenção Primária, secretarias de saúde municipal e estadual e Ministério da Saúde. Os custos foram estimados em reais (R$) para o ano de 2010.

RESULTADOS

O custo do programa em Goiânia foi de R$429.079, sendo 78,0% referentes à abordagem e tratamento do tabagismo. O custo por paciente foi de R$534 e, por paciente que deixou de fumar, de R$1.435. A implementação plena do programa no município de Goiânia geraria custo de R$20,28 milhões, para atender 35.323 fumantes.

CONCLUSÕES

O Programa de Tratamento do Tabagismo tem bom desempenho em termos de custo por paciente que deixa de fumar. Tendo em vista a carga do tabagismo no Brasil, o tratamento para cessação de fumar deve ser considerado prioritário ao se programar a alocação de recursos de saúde.

Implementation of an Inpatient Electronic Referral System (Opt-to-Quit) From the Electronic Health Record to the New York State Smokers' Quitline: First Steps

OBJECTIVES

(1) To implement a new policy-driven referral program, Opt-to-Quit, using electronic data transfer from the electronic health record (EHR) to the New York State Smokers' Quitline (NYSSQL) and (2) to improve referrals to the NYSSQL for smoking caregivers of children admitted to a children's hospital.

METHODS

Smoking caregivers of pediatric patients were referred to the NYSSQL through a standardized template built into the EHR, during the child's hospitalization or emergency department encounter. Direct data exchange was based on a point-to-point protocol, without dependence on any external centralized processing service. Input and oversight were provided by a multidisciplinary task force, which included physician and nursing leadership, information technology specialists, Health Insurance Portability and Accountability Act compliance personnel and legal counsel, and NYSSQL staff. The process was refined through several iterative plan-do-study-act cycles, using a single-armed, prospective cohort study design, including surveys of nursing staff and continued input of information technology experts on both hospital and Quitline sides.

RESULTS

In 2013, 193 smokers were identified in 2 pilot units; 62% (n= 119) accepted referral to the NYSSQL. In 2014, after expansion to all inpatient units and the emergency department, 745 smokers were identified, and 36% (n = 266) accepted referral. Over the 2 years, overall increase in referrals was 124%; as of the first quarter of 2015, referral rate was sustained at 34%.

CONCLUSIONS

Hospital-wide implementation of the Opt-to-Quit program through our EHR was feasible and sustainable and has significantly improved referrals to the NYSSQL.

Medical costs and quality-adjusted life years associated with smoking: a systematic review

BACKGROUND

Estimated medical costs ("T") and QALYs ("Q") associated with smoking are frequently used in cost-utility analyses of tobacco control interventions. The goal of this study was to understand how researchers have addressed the methodological challenges involved in estimating these parameters.

METHODS

Data were collected as part of a systematic review of tobacco modeling studies. We searched five electronic databases on July 1, 2013 with no date restrictions and synthesized studies qualitatively. Studies were eligible for the current analysis if they were U.S.-based, provided an estimate for Q, and used a societal perspective and lifetime analytic horizon to estimate T. We identified common methods and frequently cited sources used to obtain these estimates.

RESULTS

Across all 18 studies included in this review, 50 % cited a 1992 source to estimate the medical costs associated with smoking and 56 % cited a 1996 study to derive the estimate for QALYs saved by quitting or preventing smoking. Approaches for estimating T varied dramatically among the studies included in this review. T was valued as a positive number, negative number and $0; five studies did not include estimates for T in their analyses. The most commonly cited source for Q based its estimate on the Health Utilities Index (HUI). Several papers also cited sources that based their estimates for Q on the Quality of Well-Being Scale and the EuroQol five dimensions questionnaire (EQ-5D).

CONCLUSIONS

Current estimates of the lifetime medical care costs and the QALYs associated with smoking are dated and do not reflect the latest evidence on the health effects of smoking, nor the current costs and benefits of smoking cessation and prevention. Given these limitations, we recommend that researchers conducting economic evaluations of tobacco control interventions perform extensive sensitivity analyses around these parameter estimates.

You can't pay me to quit: the failure of financial incentives for smoking cessation in head and neck cancer patients

OBJECTIVE

A prospective randomised study was conducted at a tertiary care hospital to evaluate the effects of financial incentives for smoking cessation targeted at a high-risk population.

METHODS

Patients with a past history of head and neck cancer were voluntarily enrolled over a two-year period. They were randomised to a cash incentives or no incentive group. Subjects were offered enrolment in smoking cessation courses. Smoking by-product levels were assessed at 30 days, 3 months and 6 months. Subjects in the incentive group received $150 if smoking cessation was confirmed.

RESULTS

Over 2 years, 114 patients with an established diagnosis of head and neck cancer were offered enrolment. Twenty-four enrolled and 14 attended the smoking cessation classes. Only two successfully quit smoking at six months. Both these patients were in the financially incentivised group and received $150 at each test visit.

CONCLUSION

Providing a financial incentive for smoking cessation to a population already carrying a diagnosis of head and neck cancer in order to promote a positive behaviour change was unsuccessful.

Relapse-Prevention Booklets as an Adjunct to a Tobacco Quitline: A Randomized Controlled Effectiveness Trial

INTRODUCTION

Relapse prevention (RP) remains a major challenge to smoking cessation. Previous research found that a set of self-help RP booklets significantly reduced smoking relapse. This study tested the effectiveness of RP booklets when added to the existing services of a telephone quitline.

METHODS

Quitline callers (N = 3458) were enrolled after their 2-week quitline follow-up call and randomized to one of three interventions: (1) Usual Care: standard intervention provided by the quitline, including brief counseling and nicotine replacement therapy; (2) Repeated Mailings (RM): eight Forever Free RP booklets sent to participants over 12 months; and (3) Massed Mailings: all eight Forever Free RP booklets sent upon enrollment. Follow-ups were conducted at 6-month intervals, through 24 months. The primary outcome measure was 7-day-point-prevalence-abstinence.

RESULTS

Overall abstinence rates were 61.0% at baseline, and 41.9%, 42.7%, 44.0%, and 45.9% at the 6-, 12-, 18- and 24-month follow-ups, respectively. Although RM produced higher abstinence rates, the differences did not reach significance for the full sample. Post-hoc analyses of at-risk subgroups revealed that among participants with high nicotine dependence (n = 1593), the addition of RM materials increased the abstinence rate at 12 months (42.2% vs. 35.2%; OR = 1.38; 95% CI = 1.03% to 1.85%; P = .031) and 24 months (45% vs. 38.8%; OR = 1.31; 95% CI = 1.01% to 1.73%; P = .046).

CONCLUSIONS

Sending self-help RP materials to all quitline callers appears to provide little benefit to deterring relapse. However, selectively sending RP booklets to callers explicitly seeking assistance for RP and those identified as highly dependent on nicotine might still prove to be worthwhile.

Why and how would we implement a lung cancer screening program?

For decades, lung cancer has been the most common cancer in terms of both incidence and mortality. There has been very little improvement in the prognosis of lung cancer. Early treatment following early diagnosis is considered to have potential for development. The National Lung Screening Trial (NLST), a large, well-designed randomized controlled trial, evaluated low-dose computed tomography (LDCT) as a screening tool for lung cancer. Compared with chest X-ray, annual LDCT screening reduced death from lung cancer and overall mortality by 20 and 6.7 %, respectively, in high-risk people aged 55–74 years. Several smaller trials of LDCT screening are under way, but none are sufficiently powered to detect a 20 % reduction in lung cancer death. Thus, it is very unlikely that the NLST results will be replicated. In addition, the NLST raises several issues related to screening, such as the high false-positive rate, overdiagnosis and cost. Healthcare providers and systems are now left with the question of whether the available findings should be translated into practice. We present the main reasons for implementing lung cancer screening in high-risk adults and discuss the main issues related to lung cancer screening. We stress the importance of eligibility criteria, smoking cessation programs, primary care physicians, and informed-decision making should lung cancer screening be implemented. Seven years ago, we were waiting for the results of trials. Such evidence is now available. Similar to almost all other cancer screens, uncertainties exist and persist even after recent scientific efforts and data. We believe that by staying within the characteristics of the original trial and appropriately sharing the evidence as well as the uncertainties, it is reasonable to implement a LDCT lung cancer screening program for smokers and former smokers.

The Economic Impact of Smoking and of Reducing Smoking Prevalence: Review of Evidence

BACKGROUND

Tobacco smoking is the cause of many preventable diseases and premature deaths in the 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 World Health Organization (WHO) estimates that, globally, smoking causes over US$500 billion in economic damage each year.

OBJECTIVES

This paper examines global and UK evidence on the economic impact of smoking prevalence and evaluates the effectiveness and cost effectiveness of smoking cessation measures.

STUDY SELECTION

SEARCH METHODS We used two major health care/economic research databases, namely PubMed and the National Institute for Health Research (NIHR) database that contains the British National Health Service (NHS) Economic Evaluation Database; Cochrane Library of systematic reviews in health care and health policy; and other health-care-related bibliographic sources. We also performed hand searching of relevant articles, health reports, and white papers issued by government bodies, international health organizations, and health intervention campaign agencies. SELECTION CRITERIA The paper includes cost-effectiveness studies from medical journals, health reports, and white papers published between 1992 and July 2014, but included only eight relevant studies before 1992. Most of the papers reviewed reported outcomes on smoking prevalence, as well as the direct and indirect costs of smoking and the costs and benefits of smoking cessation interventions. We excluded papers that merely described the effectiveness of an intervention without including economic or cost considerations. We also excluded papers that combine smoking cessation with the reduction in the risk of other diseases. DATA COLLECTION AND ANALYSIS The included studies were assessed against criteria indicated in the Cochrane Reviewers Handbook version 5.0.0. OUTCOMES ASSESSED IN THE REVIEWPrimary outcomes of the selected studies are smoking prevalence, direct and indirect costs of smoking, and the costs and benefits of smoking cessation interventions (eg, "cost per quitter", "cost per life year saved", "cost per quality-adjusted life year gained," "present value" or "net benefits" from smoking cessation, and "cost savings" from personal health care expenditure).

MAIN RESULTS

The main findings of this study are as follows: The costs of smoking can be classified into direct, indirect, and intangible costs. 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.The costs of smoking notwithstanding, it produces some potential economic benefits. 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.Smoking cessation measures could range from pharmacological treatment interventions to policy-based measures, community-based interventions, telecoms, media, and technology (TMT)-based interventions, school-based interventions, and workplace interventions.The cost per life year saved from the use of pharmacological treatment interventions ranged between US$128 and US$1,450 and up to US$4,400 per quality-adjusted life years (QALYs) saved. The use of pharmacotherapies such as varenicline, NRT, and Bupropion, when combined with GP counseling or other behavioral treatment interventions (such as proactive telephone counseling and Web-based delivery), is both clinically effective and cost effective to primary health care providers.Price-based policy measures such as increase in tobacco taxes are unarguably the most effective means of reducing the consumption of tobacco. A 10% tax-induced cigarette price increase anywhere in the world reduces smoking prevalence by between 4% and 8%. Net public benefits from tobacco tax, however, remain positive only when tax rates are between 42.9% and 91.1%. The cost effectiveness ratio of implementing non-price-based smoking cessation legislations (such as smoking restrictions in work places, public places, bans on tobacco advertisement, and raising the legal age of smokers) range from US$2 to US$112 per life year gained (LYG) while reducing smoking prevalence by up to 30%-82% in the long term (over a 50-year period).Smoking cessation classes are known to be most effective among community-based measures, as they could lead to a quit rate of up to 35%, but they usually incur higher costs than other measures such as self-help quit-smoking kits. On average, community pharmacist-based smoking cessation programs yield cost savings to the health system of between US$500 and US$614 per LYG.Advertising media, telecommunications, and other technology-based interventions (such as TV, radio, print, telephone, the Internet, PC, and other electronic media) usually have positive synergistic effects in reducing smoking prevalence especially when combined to deliver smoking cessation messages and counseling support. However, the outcomes on the cost effectiveness of TMT-based measures have been inconsistent, and this made it difficult to attribute results to specific media. The differences in reported cost effectiveness may be partly attributed to varying methodological approaches including varying parametric inputs, differences in national contexts, differences in advertising campaigns tested on different media, and disparate levels of resourcing between campaigns. Due to its universal reach and low implementation costs, online campaign appears to be substantially more cost effective than other media, though it may not be as effective in reducing smoking prevalence.School-based smoking prevalence programs tend to reduce short-term smoking prevalence by between 30% and 70%. Total intervention costs could range from US$16,400 to US$580,000 depending on the scale and scope of intervention. 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.Workplace-based interventions could represent a sound economic investment to both employers and the society at large, achieving a benefit-cost ratio of up to 8.75 and generating 12-month employer cost savings of between $150 and $540 per nonsmoking employee. Implementing smoke-free workplaces would also produce myriads of new quitters and reduce the amount of cigarette consumption, leading to cost savings in direct medical costs to primary health care providers. Workplace interventions are, however, likely to yield far greater economic benefits over the long term, as reduced prevalence will lead to a healthier and more productive workforce.

CONCLUSIONS

We conclude that the direct costs and externalities to society of smoking far outweigh any benefits that might be accruable at least when considered from the perspective of socially desirable outcomes (ie, in terms of a healthy population and a productive 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.

Mathematical Modeling in Tobacco Control Research: Initial Results From a Systematic Review

OBJECTIVES

The US Food and Drug Administration has expressed interest in using mathematical models to evaluate potential tobacco policies. The goal of this systematic review was to synthesize data from tobacco control studies that employ mathematical models.

METHODS

We searched five electronic databases on July 1, 2013 to identify published studies that used a mathematical model to project a tobacco-related outcome and developed a data extraction form based on the ISPOR-SMDM Modeling Good Research Practices. We developed an organizational framework to categorize these studies and identify models employed across multiple papers. We synthesized results qualitatively, providing a descriptive synthesis of included studies.

RESULTS

The 263 studies in this review were heterogeneous with regard to their methodologies and aims. We used the organizational framework to categorize each study according to its objective and map the objective to a model outcome. We identified two types of study objectives (trend and policy/intervention) and three types of model outcomes (change in tobacco use behavior, change in tobacco-related morbidity or mortality, and economic impact). Eighteen models were used across 118 studies.

CONCLUSIONS

This paper extends conventional systematic review methods to characterize a body of literature on mathematical modeling in tobacco control. The findings of this synthesis can inform the development of new models and the improvement of existing models, strengthening the ability of researchers to accurately project future tobacco-related trends and evaluate potential tobacco control policies and interventions. These findings can also help decision-makers to identify and become oriented with models relevant to their work.

Estimates of price and income elasticity in Greece. Greek debt crisis transforming cigarettes into a luxury good: an econometric approach

OBJECTIVE

During the past decades, smoking prevalence in Greece was estimated to be near or over 40%. Following a sharp fall in cigarette consumption, as shown in current data, our objective is to assess smokers' sensitivity to cigarette price and consumer income changes as well as to project health benefits of an additional tax increase.

METHODS

Cigarette consumption was considered as the dependent variable, with Weighted Average Price as a proxy for cigarette price, gross domestic product as a proxy for consumers' income and dummy variables reflecting smoking restrictions and antismoking campaigns. Values were computed to natural logarithms and regression was performed. Then, four scenarios of tax increase were distinguished in order to calculate potential health benefits.

RESULTS

Short-run price elasticity is estimated at -0.441 and short-run income elasticity is estimated at 1.040. Antismoking campaigns were found to have a statistically significant impact on consumption. Results indicate that, depending on the level of tax increase, annual per capita consumption could fall by at least 209.83 cigarettes; tax revenue could rise by more than €0.74 billion, while smokers could be reduced by up to 530 568 and at least 465 smoking-related deaths could be averted.

CONCLUSIONS

Price elasticity estimates are similar to previous studies in Greece, while income elasticity estimates are far greater. With cigarettes regarded as a luxury good, a great opportunity is presented for decisionmakers to counter smoking. Increased taxation, along with focused antismoking campaigns, law reinforcement (to ensure compliance with smoking bans) and intensive control for smuggling could invoke a massive blow to the tobacco epidemic in Greece.

A Systematic Review and Meta-analysis of the Acceptability and Effectiveness of University Smoke-Free Policies

OBJECTIVE

Systematically review studies of support for, and effectiveness of, university campuses' smoke-free policies.

PARTICIPANTS/METHODS

A search was carried out for studies in English related to campus smoking bans through June 2013. Eligible studies had outcomes for student or faculty attitudes, or measures of smoking prevalence or secondhand smoke (SHS) exposure.

RESULTS

Nineteen eligible studies were identified, 18 from the United States and 1 from the United Kingdom. A meta-analysis found 58.94% (95% confidence interval [CI] [52.35%, 65.53%]) of students (12 studies) and 68.39% (95% CI [65.12%, 71.67%]) of faculty (7 studies) supported smoke-free policies. Both studies measuring student smoking prevalence indicated a postban reduction (16.5% to 12.8% after 1 year [p < .001] and 9.5% to 7.0% [p = .036] after 3 years). Only 5% of UK universities were smoke-free compared with 25% of US universities.

CONCLUSIONS

A majority of students and faculty support smoke-free campus policies, which may reduce smoking and SHS exposure.

Self-efficacy and acceptance of cravings to smoke underlie the effectiveness of quitline counseling for smoking cessation

BACKGROUND

Few studies have examined why smoking cessation interventions are effective. The aim of this study was to examine the mediating processes underlying the effectiveness of cessation counseling administered by the Dutch national quitline.

METHODS

Data were used of a two-arm randomized controlled trial in which smoking parents, who were recruited through primary schools in The Netherlands, received either quitline cessation counseling (n=256) or a self-help brochure (n=256). The endpoint was 6-months prolonged abstinence at 12-months follow-up, with 86.7% outcome data retention. Putative psychological mediators of treatment effectiveness included smoking-related cognitions (positive smoking outcome expectancies, self-efficacy), emotions (negative affect, perceived stress, depressive symptoms), and smoking cue coping methods (avoidance coping, acceptance coping) assessed at 3-months post-measurement.

RESULTS

Quitline cessation counseling significantly decreased positive smoking outcome expectancies and negative affect and increased self-efficacy to refrain from smoking, avoidance of external cues to smoking, and acceptance of internal cues to smoking compared to self-help material. Increased self-efficacy to refrain from smoking in stressful and tempting situations (p<.001) and increased acceptance of cravings to smoke (p<.001) significantly mediated the effect of quitline cessation counseling on prolonged abstinence at 12-months follow-up (explained variance: 25.1%).

CONCLUSIONS

Self-efficacy to refrain from smoking and acceptance of cravings represent an important source of therapeutic change in smoking cessation counseling.

Economic evaluation of a hospital-initiated intervention for smokers with chronic disease, in Ontario, Canada

Introduction

Cigarette smoking causes many chronic diseases that are costly and result in frequent hospitalisation. Hospital-initiated smoking cessation interventions increase the likelihood that patients will become smoke-free. We modelled the cost-effectiveness of the Ottawa Model for Smoking Cessation (OMSC), an intervention that includes in-hospital counselling, pharmacotherapy and posthospital follow-up, compared to usual care among smokers hospitalised with acute myocardial infarction (AMI), unstable angina (UA), heart failure (HF), and chronic obstructive pulmonary disease (COPD).

Methods

We completed a cost-effectiveness analysis based on a decision-analytic model to assess smokers hospitalised in Ontario, Canada for AMI, UA, HF, and COPD, their risk of continuing to smoke and the effects of quitting on re-hospitalisation and mortality over a 1-year period. We calculated short-term and long-term cost-effectiveness ratios. Our primary outcome was 1-year cost per quality-adjusted life year (QALY) gained.

Results

From the hospital payer's perspective, delivery of the OMSC can be considered cost effective with 1-year cost per QALY gained of $C1386, and lifetime cost per QALY gained of $C68. In the first year, we calculated that provision of the OMSC to 15 326 smokers would generate 4689 quitters, and would prevent 116 rehospitalisations, 923 hospital days, and 119 deaths. Results were robust within numerous sensitivity analyses.

Discussion

The OMSC appears to be cost-effective from the hospital payer perspective. Important consideration is the relatively low intervention cost compared to the reduction in costs related to readmissions for illnesses associated with continued smoking.

Genetic test to stop smoking (GeTSS) trial protocol: randomised controlled trial of a genetic test (Respiragene) and Auckland formula to assess lung cancer risk

BACKGROUND

A gene-based estimate of lung cancer risk in smokers has been shown to act as a smoking cessation motivator in hospital recruited subjects. The objective of this trial is to determine if this motivator is as effective in subjects recruited from an NHS primary care unit.

METHOD/DESIGN

Subjects will be recruited by mailings using smoking entries on the GP electronic data-base (total practice population = 32,048) to identify smokers who may want to quit. Smoking cessation clinics based on medical centre premises will run for eight weeks. Clinics will be randomised to have the gene-based test for estimation of lung cancer risk or to act as controls groups. The primary endpoint will be smoking cessation at eight weeks and six months. Secondary outcomes will include ranking of the gene-based test with other smoking cessation motivators.

DISCUSSION

The results will inform as to whether the gene-based test is both effective as motivator and acceptable to subjects recruited from primary care.

TRIAL REGISTRATION

Registered with Clinical Trials.gov,

REGISTRATION NUMBER

NCT01176383.

Using a health informatics system to assess effect of a federal cigarette tax increase on readiness to quit among low-income smokers, Louisiana, 2009

Introduction

Health informatics systems are a proven tool for tobacco control interventions. To address the needs of low-income groups, the Tobacco Control Initiative was established in partnership with the Louisiana State University Health Care Services Division to provide cost-effective tobacco use cessation services through the health informatics system in the state public hospital system.

Methods

In this study we used a Web-based, result-reporting application to monitor and assess the effect of the 2009 federal cigarette tax increase. We assessed readiness to quit tobacco use before and after a cigarette tax increase among low-income tobacco users who were outpatients in a public hospital system.

Results

Overall, there was an increase in readiness to quit, from 22% during the first week of February to 33% during the first week of April, when the tax went into effect. Smokers who were female, 31 or older, African American, and assessed at a clinic visit in April were more likely to report readiness to quit than were men, those aged 30 or younger, those who were white, and those who were assessed at a clinic visit in February.

Conclusion

A health informatics system that efficiently tracks trends in readiness to quit can be used in combination with other strategies and thus optimize efforts to control tobacco use. Our data suggest that a cigarette tax increase affects smokers’ readiness to quit and provides an opportunity to intervene at the most beneficial time.

Cost-effectiveness of internet and telephone treatment for smoking cessation: an economic evaluation of The iQUITT Study

BACKGROUND

Internet and telephone treatments for smoking cessation can reach large numbers of smokers. There is little research on their costs and the impact of adherence on costs and effects.

OBJECTIVE

To conduct an economic evaluation of The iQUITT Study, a randomised trial comparing Basic Internet, Enhanced Internet and Enhanced Internet plus telephone counselling ('Phone') at 3, 6, 12 and 18 months.

METHODS

We used a payer perspective to evaluate the average and incremental cost per quitter of the three interventions using intention-to-treat analysis of 30-day single-point prevalence and multiple-point prevalence (MPP) abstinence rates. We also examined results based on adherence. Costs included commercial charges for each intervention. Discounting was not included given the short time horizon.

RESULTS

Basic Internet had the lowest cost per quitter at all time points. In the analysis of incremental costs per additional quitter, Enhanced Internet+Phone was the most cost-effective using both single and MPP abstinence metrics. As adherence increased, the cost per quitter dropped across all arms. Costs per quitter were lowest among participants who used the 'optimal' level of each intervention, with an average cost per quitter at 3 months of US$7 for Basic Internet, US$164 for Enhanced Internet and US$346 for Enhanced Internet+Phone.

CONCLUSIONS

'Optimal' adherence to internet and combined internet and telephone interventions yields the highest number of quitters at the lowest cost. Cost-effective means of ensuring adherence to such evidence-based programmes could maximise their population-level impact on smoking prevalence.

Long-term follow-up of a high- and a low-intensity smoking cessation intervention in a dental setting--a randomized trial

Background

Achieving lifelong tobacco abstinence is an important public health goal. Most studies use 1-year follow-ups, but little is known about how good these are as proxies for long-term and life-long abstinence. Also, intervention intensity is an important issue for development of efficient and cost-effective cessation treatment protocols.

The study aims were to assess the long-term effectiveness of a high- and a low-intensity treatment (HIT and LIT) for smoking cessation and to analyze to what extent 12-month abstinence predicted long-term abstinence.

Methods

300 smokers attending dental or general health care were randomly assigned to HIT or LIT at the public dental clinic. Main outcome measures were self-reported point prevalence, continuous abstinence (≥6 months), and sustained abstinence. The study was a follow-up after 5–8 years of a previously performed 12-month follow-up, both by postal questionnaires.

Results

Response rate was 85% (n=241) of those still alive and living in Sweden. Abstinence rates were 8% higher in both programs at the long-term than at the 12-month follow-up. The difference of 7% between HIT and LIT had not change, being 31% vs. 24% for point prevalence and 26% vs. 19% for 6-month continuous abstinence, respectively. Significantly more participants in HIT (12%) than in LIT (5%) had been sustained abstinent (p=0.03). Logistic regression analyses showed that abstinence at 12-month follow-up was a strong predictor for abstinence at long-term follow-up.

Conclusions

Abstinence at 12-month follow-up is a good predictor for long-term abstinence. The difference in outcome between HIT and LIT for smoking cessation remains at least 5–8 years after the intervention.

Trial registration number

NCT00670514

The effects of Medicaid policy changes on adults' service use patterns in Kentucky and Idaho

BACKGROUND

In 2006, Idaho and Kentucky became two of the first states to implement changes to their Medicaid programs under authority granted by the 2005 Deficit Reduction Act (DRA). The DRA granted new flexibility in the design of state Medicaid programs, including a state plan amendment (SPA) option for changes that previously would have required a waiver. This paper uses state Medicaid administrative data to analyze the impact of Medicaid policy changes implemented in these states through a series of SPAs in 2006 and 2007.

METHODS

Changes in utilization are examined for multiple services, including physician, dental, and ER visits, inpatient stays, and prescriptions, among non-elderly adult Medicaid recipients following changes in cost sharing, reimbursement, service delivery, and covered services. Where possible, enrollees not affected by the changes served as a comparison group.

RESULTS

While relatively few adults in Idaho received a wellness exam after such coverage was added, the adoption of managed care for dental services was associated with increased receipt of dental care, including preventive care. The new limits on brand name prescriptions in Kentucky were associated with a reduction in the proportion of enrollees with two or more monthly name brand prescriptions while the small copayments introduced did not appear to have a dramatic impact.

CONCLUSIONS

We find that changes in financial incentives on both the supply-side (such as reimbursement increases) and the demand-side (i.e., benefit changes) alone may not be enough to generate the desired levels of preventive care, especially among those with chronic health conditions.

The Associations Between Smoking and Occupational Categories

The implementation of smoke-free policies for workplaces and their impacts have been far from satisfactory. We investigated smoking prevalence in various occupations using data (n = 9283) from the Korea National Health and Nutrition Examination Survey collected from 2008 to 2010. Young adults who were working in the occupation categories of “service and sales,” “skilled agricultural, fishery, and forest workers,” and “crafts and machine operation” for men and “service and sales” for women showed 1.8 to 7.1 and 3.7 times higher ( P < .05) smoking prevalence compared with the reference (managers and professionals), respectively, and the highest prevalence among the 7 occupational categories that were studied. Drinking and stress level were positively associated with being current smokers. We provide quantitative evidence supporting clinicians and policy makers wishing to establish smoking-cessation programs in workplaces for young adults in South Korea, and evidence supporting the improvement of prevention by the concomitant reduction of risk factors.

Impact of educational intervention on implementation of tobacco counselling among oral health professionals: a cluster-randomized community trial

OBJECTIVES

Tobacco use adversely affects oral health. Clinical guidelines recommend that oral health professionals promote tobacco abstinence and provide patients who use tobacco with brief tobacco use cessation counselling. Research shows that these guidelines are seldom implemented successfully. This study aimed to evaluate two interventions to enhance tobacco use prevention and cessation (TUPAC) counselling among oral health professionals in Finland.

METHODS

We used a cluster-randomized community trial to test educational and fee-for-service interventions in enhancing TUPAC counselling among a sample of dentists (n=73) and dental hygienists (n=22) in Finland. Educational intervention consisted of 1 day of training, including lectures, interactive sessions, multimedia demonstrations and a role play session with standard patient cases. Fee-for-service intervention consisted of monetary compensation for providing tobacco use prevention or cessation counselling. TUPAC counselling procedures provided were reported and measured using an electronic dental records system. In data analysis, intent-to-treat principles were followed at both individual and cluster levels. Descriptive analysis included chi-square and t-tests. A general linear model for repeated measures was used to compare the outcome measures by intervention group.

RESULTS

Of 95 providers, 73 participated (76.8%). In preventive counselling, there was no statistically significant time effect or group-by-time interaction. In cessation counselling, statistically significant group-by-time interaction was found after a 6-month follow-up (F=2.31; P=0.007), indicating that counselling activity increased significantly in intervention groups. On average, dental hygienists showed greater activity in tobacco prevention (F=12.13; P=0.001) and cessation counselling (F=30.19; P<0.001) than did dentists. In addition, cessation counselling showed a statistically significant provider-by-group-by-time interaction (F=5.95; P<0.001), indicating that interventions to enhance cessation counselling were more effective among dental hygienists.

CONCLUSIONS

Educational intervention yielded positive short-term effects on cessation counselling, but not on preventive counselling. Adding a fee-for-service to education failed to significantly improve TUPAC counselling performance. Other approaches than monetary incentives may be needed to enhance the effectiveness of educational intervention. Further studies with focus on how to achieve long-term changes in TUPAC counselling activity among oral health professionals are needed.

Prioritizing risk factors to identify preventive interventions for economic assessment

OBJECTIVE

To explore a risk factor approach for identifying preventive interventions that require more in-depth economic assessment, including cost-effectiveness analyses.

METHODS

A three-step approach was employed to: (i) identify the risk factors that contribute most substantially to disability-adjusted life years (DALYs); (ii) re-rank these risk factors based on the availability of effective preventive interventions warranting further cost-effectiveness analysis (and in some instances on evidence from existing cost-effectiveness analyses); and (iii) re-rank these risk factors in accordance with their relative contribution to health inequalities. Health inequalities between the Māori and non-Māori populations in New Zealand were used by way of illustration.

FINDINGS

Seven of the top 10 risk factors prioritized for research on preventive interventions in New Zealand were also among the 10 risk factors most highly ranked as contributing to DALYs in high-income countries of the World Health Organization's Western Pacific Region. The final list of priority risk factors included tobacco use; alcohol use; high blood pressure; high blood cholesterol; overweight/obesity, and physical inactivity. All of these factors contributed to health inequalities. Effective interventions for preventing all of them are available, and for each risk factor there is at least one documented cost-saving preventive intervention.

CONCLUSION

The straightforward approach to prioritizing risk factors described in this paper may be applicable in many countries, and even in those countries that lack the capacity to perform additional cost-effectiveness analyses, this approach will still make it possible to determine which cost-effective interventions should be implemented in the short run.

Program, policy, and price interventions for tobacco control: quantifying the return on investment of a state tobacco control program

OBJECTIVES

We examined health effects associated with 3 tobacco control interventions in Washington State: a comprehensive state program, a state policy banning smoking in public places, and price increases.

METHODS

We used linear regression models to predict changes in smoking prevalence and specific tobacco-related health conditions associated with the interventions. We estimated dollars saved over 10 years (2000-2009) by the value of hospitalizations prevented, discounting for national trends.

RESULTS

Smoking declines in the state exceeded declines in the nation. Of the interventions, the state program had the most consistent and largest effect on trends for heart disease, cerebrovascular disease, respiratory disease, and cancer. Over 10 years, implementation of the program was associated with prevention of nearly 36,000 hospitalizations, at a value of about $1.5 billion. The return on investment for the state program was more than $5 to $1.

CONCLUSIONS

The combined program, policy, and price interventions resulted in reductions in smoking and related health effects, while saving money. Public health and other leaders should continue to invest in tobacco control, including comprehensive programs.

Population-based smoking cessation strategies: a summary of a select group of evidence-based reviews

OBJECTIVE

The objective of this report was to provide the Ministry of Health Promotion (MHP) with a summary of existing evidence-based reviews of the clinical and economic outcomes of population-based smoking cessation strategies.

BACKGROUND

Tobacco use is the leading cause of preventable disease and death in Ontario, linked to approximately 13,000 avoidable premature deaths annually - the vast majority of these are attributable to cancer, cardiovascular disease, and chronic obstructive lung disease. (1) In Ontario, tobacco related health care costs amount to $6.1 billion annually, or about $502 per person (including non-smokers) and account for 1.4% of the provincial domestic product. (2) In 2007, there were approximately 1.7 to 1.9 million smokers in Ontario with two-thirds of these intending to quit in the next six months and one-third wanting to quit within 30 days. (3) In 2007/2008, Ontario invested $15 million in cessation programs, services and training. (4) In June 2009, the Ministry of Health Promotion (MHP) requested that MAS provide a summary of the evidence base surrounding population-based smoking cessation strategies. PROJECT SCOPE: The MAS and the MHP agreed that the project would consist of a clinical and economic summary of the evidence surrounding nine population-based strategies for smoking cessation including: Mass media interventionsTelephone counsellingPost-secondary smoking cessation programs (colleges/universities)Community-wide stop-smoking contests (i.e. Quit and Win)Community interventionsPhysician advice to quitNursing interventions for smoking cessationHospital-based interventions for smoking cessationPharmacotherapies for smoking cessation, specifically:Nicotine replacement therapiesAntidepressantsAnxiolytic drugsOpioid antagonistsClonidineNicotine receptor partial agonistsReviews examining interventions for Cut Down to Quit (CDTQ) or harm reduction were not included in this review. In addition, reviews examining individual-level smoking cessation strategies (i.e. self-help interventions, counselling, etc.), web-based smoking cessation interventions, and smoking cessation strategies for special population groups outside of those identified from reviews included in this analysis were excluded from the scope. Information on cessation programs or strategies in other provinces or an evaluation of current population-based programs in Ontario was also not included in the scope. STATUS IN ONTARIO: In 2005, the McGuinty government launched the Smoke-Free Ontario Strategy, focusing on initiatives aimed at young people to encourage them not to smoke, protection from exposure to second-hand smoke, and programs to help smokers quit. There are currently many smoking cessation programs funded across the province and in 2007/2008, Ontario invested $15 million in cessation programs, services and training. Ontario Health Insurance Plan (OHIP) fee codes for physician advice to quit also exist. EVIDENCE-BASED ANALYSIS:

RESEARCH QUESTION

What are the efficacy and cost-effectiveness of the selected population-based strategies for smoking cessation?

LITERATURE SEARCH

A preliminary scan of Medline was conducted to identify major systematic reviews, meta-analyses, and health technology assessments (HTAs) in the area of smoking cessation. Based on the availability of a number of Cochrane Reviews on the topic of smoking cessation, a more systematic search of the literature was not conducted. For the economic analysis, a literature search was conducted of relevant databases for recently published article reviews, HTAs, and Cochrane Reviews of the nine identified population-based smoking cessation strategies. This analysis is limited as it is a summary of existing reviews and not a systematic review.

OUTCOMES OF INTEREST

The primary outcome of interest for the clinical summary was abstinence from smoking at 6 months follow up; additional outcomes were examined where available. The primary outcomes of interest for the economic analysis were cost-effectiveness ratios.

SUMMARY OF FINDINGS

The evidence suggests that pharmacotherapy, physician advice to quit, nursing interventions, hospital-based interventions, and proactive telephone counselling are effective and cost-effective in the short-term.There is poor quality data around other population-based smoking cessation strategies including mass media campaigns, community interventions, quit and win contests, access to 'quitlines', and interventions for university and college campuses, making evaluation of their effectiveness and cost-effectiveness difficult.Based on pooled summary estimates of effect and safety data, the most effective strategies are varenicline, buproprion, and nicotine replacement therapies, followed by physician advice to quit and nursing interventions (in non-hospitalized smokers without cardiovascular disease).