Systems Change: Evidence (continued)

Cost-Effectiveness of Tobacco Dependence Interventions

Recommendation: The tobacco dependence treatments shown to be effective in this guideline (both counseling and medication) are highly cost-effective relative to other reimbursed treatments and should be provided to all smokers. (Strength of Evidence = A)

Recommendation: Sufficient resources should be allocated for systems support to ensure the delivery of efficacious tobacco use treatments. (Strength of Evidence = C)

Smoking exacts a substantial financial burden on the United States. A recent report of the United States Centers for Disease Control and Prevention estimated that tobacco dependence costs the nation more than $96 billion per year in direct medical expenses and $97 billion in lost productivity.²⁸ Given these substantial costs, research has focused on the economic impact and cost-effectiveness of tobacco cessation interventions.

Tobacco use treatments, ranging from brief clinician advice to specialist-delivered intensive programs, including medication, have been shown to be not only clinically effective, but also extremely cost-effective relative to other commonly used disease prevention interventions and medical treatments. Cost-effectiveness analyses have shown that tobacco dependence treatment compares quite favorably with routinely reimbursed medical interventions such as the treatment of hypertension and hypercholesterolemia as well as preventive screening interventions such as periodic mammography or Papanicolaou smears.^{222,224,374-382} For example, the cost per life-year saved of tobacco dependence treatment has been estimated at $3,539,¹⁹⁴ which compares favorably to hypertension screening for men, ages 45-54 ($5,200) and annual cervical screening for women, ages 34-39, ($4,100).³⁸³ Treating tobacco dependence also is important economically in that it can prevent the development of a variety of costly chronic diseases, including heart disease, cancer, and pulmonary disease. In fact, tobacco dependence treatment has been referred to as the "gold standard" of health care cost effectiveness.²²⁵

Cost-effectiveness can be measured in a variety of ways, including cost per quality-adjusted-life-year saved (QALY), cost per quit, health care costs and utilization pre- and post-quit, and return on investment (ROI) for coverage of tobacco dependence treatment.

Cost per Quality-Adjusted-Life-Year Saved and Cost per Quit

Numerous analyses have estimated the cost per Quality-Adjusted-Life-Year (QALY) saved resulting from use of effective tobacco dependence interventions.^{187,222,380,384-389} In general, evidence-based tobacco use interventions compare quite favorably with other prevention and chronic disease interventions such as treatment of hypertension and mammography screening when using this criterion. Specific analyses have estimated the costs of tobacco use treatment to range from a few hundred to a few thousand dollars per QALY saved.^228,385 Separate analyses have computed the estimated costs of treatment in terms of the cost per quit. Compared to other interventions, the cost of tobacco use treatments has been modest, ranging from a few hundred to a few thousand dollars per quit.^{194,212,384,390-393}

Managed Care Organizations (MCOs) often assess the per member per month (PMPM) cost of a benefit and the PMPM for tobacco use treatment has been assessed in a variety of settings. In general, the PMPM for tobacco use treatments have been low relative to other covered benefits, ranging from about $0.20 to about $0.80 PMPM.^{210,228,391,394}

Health care Costs and Utilization Pre- and Post-Quit

A substantial body of research has investigated the effect of tobacco use treatment on health care costs.^395-399 A synthesis of these findings suggests that: 1) among individuals who quit tobacco use, health care costs typically increase during the year in which smokers quit then decline progressively, falling below those of continuing smokers for one to 10 years after quitting; 2) in general, smokers' health care costs begin to rise in the time period immediately prior to quit attempts; and 3) higher health care utilization predicts smoking cessation among smokers with and without chronic diseases. These findings suggest that quitting smoking often occurs in response to serious and expensive health problems. Such research also suggests that increases in health care costs, including hospitalizations, during the year of quitting may be a cause rather than a consequence of successful smoking cessation.

Return on Investment for Coverage of Tobacco Dependence Treatment

Return on investment (ROI) is a frequently used tool to estimate the amount of time it takes for an expenditure to earn back some or all of its initial investment. The economic arguments supporting the decision to provide insurance coverage for tobacco use treatments would be enhanced if the costs of such coverage are modest compared to economic benefits resulting from successful cessation (reductions in health care expenditures, increased productivity, and/or other costs).

Studies have documented that tobacco dependence treatments provide a timely return on investment when considered by the employer. Such analyses have concluded that providing coverage for tobacco use treatment for employees often produce substantial net financial savings through increased health care savings, increased productivity, reduced absenteeism, and reduced life insurance payouts.^229,400-402

Financial savings are more difficult to attain for a health plan given factors such as member turnover, the difficulty of attributing reduced health care expenditures to tobacco dependence, and the absence of economic benefits resulting from productivity gains. Although most analyses have not demonstrated cost savings, insurance coverage of evidence-based tobacco dependence treatments are highly cost-effective relative to other frequently paid-for health care services. One recent effort to simulate the financial implications of covering tobacco use treatments by managed care organizations found that at five years, coverage of tobacco use treatment cost an MCO a modest $0.61 PMPM, with quitters gaining an average of 7.1 years of life and a direct coverage cost of about $3,500 for each life-year saved.²²⁸ The authors concluded that coverage of such cost-effective tobacco use treatment programs by MCOs should be strongly encouraged. Another study examined the trend in health care costs for former smokers over 7 years post-quitting compared to continuing smokers.³⁹⁵ The authors found that, by the seventh year, former smokers' cumulative costs (including increased cost in the year they quit) were lower than those of continuing smokers. A more recent analysis concluded that at 10 years, the ROI of providing a comprehensive tobacco use treatment benefit, considering only health care costs, ranged from 75-to-92 percent, indicating that health care savings alone have repaid more than three-fourths of the investment.²²⁹ Other analyses have shown that multiple tobacco use treatment components, including telephone counseling and various medications, yield a favorable ROI.^227,403-404 The American Health Insurance Plans (AHIP), has provided a web link for health plans to compute their ROI for the provision of tobacco use treatment: http://www.businesscaseroi.org/roi/default.aspx

Tobacco cessation treatment is particularly cost-effective in certain populations such as hospitalized patients and pregnant women. For hospitalized patients, successful tobacco abstinence not only reduces general medical costs in the short-term, but also reduces the number of future hospitalizations.^9,355,405 Tobacco dependence interventions for pregnant women are especially cost-effective because they result in fewer low birth weight babies and perinatal deaths; fewer physical, cognitive, and behavioral problems during infancy and childhood; and yield important health benefits for the mother.^406-407 One study found that interventions with U.S. pregnant smokers could net savings up to $8 million in direct neonatal inpatient costs given the cost of an intervention ($24-$34) versus the costs saved ($881) for each woman who quits smoking during pregnancy.⁴⁰⁸ Another study showed that, for each low-income pregnant smoker who quit, Medicaid saved $1,274.⁴⁰⁹ A simulation study found that a 1% point decrease in smoking prevalence among U.S. pregnant women would save $21 million (1995 dollars) in direct medical costs in the first year.^406,410-411

Return to Contents

Tobacco-Dependence Treatment as a Part of Assessing Health Care Quality

Recommendation: Provision of Guideline-based interventions to treat tobacco use and dependence should remain in standard ratings and measures of overall health care quality (e.g., NCQA HEDIS). These standard measures should also include measures of outcomes (e.g., use of cessation treatment, short- and long-term abstinence rates) that result from providing tobacco dependence interventions. (Strength of Evidence = C)

The provision of tobacco dependence treatment should be increased by: (1) attention to health organization "report cards" (e.g., HEDIS, The Joint Commission, Physician Consortium for Performance Improvement, National Quality Forum, Ambulatory Quality Alliance),^89,412-414 which support smoker identification and treatment; (2) accreditation criteria used by The Joint Commission and other accrediting bodies that include the presence of effective tobacco assessment and intervention policies; and (3) increasing the use of tobacco-related measures in pay-for-performance initiatives.

Future Research

The following topics regarding cost-effectiveness and health systems require additional research:

• Cost-effectiveness of the various tobacco dependence treatments, both short- and long-term
• Optimal ways to remove systemic barriers that prevent clinicians from effectively delivering tobacco dependence treatments
• Systemic interventions to encourage provider and patient utilization of effective tobacco dependence treatments
• Relative costs and economic impacts of different formats of effective treatments (e.g., proactive telephone counseling, face-to-face contact, medication).

Impact of using tobacco intervention performance measures on clinician intervention and patient outcomes, including the use of such measures in "pay for performance" programs.

Return to Contents

Providing Treatment for Tobacco Use and Dependence as a Covered Benefit

Recommendation: Providing tobacco dependence treatments (both medication and counseling) as a paid or covered benefit by health insurance plans has been shown to increase the proportion of smokers who use cessation treatment, attempt to quit, and successfully quit. Therefore, treatments shown to be effective in the Guideline should be included as covered services in public and private health benefit plans. (Strength of Evidence = A)

Multiple studies have assessed the impact of including tobacco dependence treatment as a covered health insurance benefit for smokers. Most studies have documented that such health insurance coverage increases both treatment utilization rates and the rates of cessation,^{210,212,391,415} although some research is not consistent with these findings.⁴¹⁶ A recent Cochrane analysis(2005) concluded that health care financing systems that offered full payment for tobacco use treatment increased self-reported prolonged abstinence rates at relatively low costs when compared with a partial benefit or no benefit. Moreover, the presence of prepaid or discounted prescription drug benefits increases patients' receipt of medication and smoking abstinence rates.^231,348,417 These studies emphasize that removing all cost barriers yields the highest rates of treatment utilization.

Three studies met criteria to be included in a 2008 Guideline Update meta-analysis of the effects of providing tobacco use treatments as a covered health insurance benefit. Three different outcomes were examined: rates of treatment provision, quit attempts, and quit rates. As can be seen in Tables 6.37 through 6.39, compared to not having tobacco use treatment as a covered benefit, individuals with the benefit were more likely to receive treatment, make a quit attempt and attain abstinence from smoking.

Table 6.37. Meta-analysis (2008): Estimated rates of intervention for individuals who received tobacco use interventions as a covered health insurance benefit (n = 3 studies)

Treatment	Number of arms	Estimated odds ratio (95% C.I.)	Estimated Intervention rate (95% C.I.)
No intervention	3	1.0	8.9
Clinician training	3	2.3 (1.8-2.9)	18.2 (14.8-22.3)

Select for the articles used in the Update's meta-analysis.

Table 6.38. Meta-analysis (2008): Estimated rates of quit attempts for individuals who received tobacco use interventions as a covered health insurance benefit (n = 3 studies)

Treatment	Number of arms	Estimated odds ratio (95% C.I.)	Estimated quit attempt rate (95% C.I.)
No intervention	3	1.0	30.5
Clinician training	3	1.3 (1.01-1.5)	36.2 (32.3-40.2)

Select for the articles used in the Update's meta-analysis.

Table 6.39. Meta-analysis (2008): Estimated abstinence rates for individuals who received tobacco use interventions as a covered benefit (n = 3 studies)

Treatment	Number of arms	Estimated odds ratio (95% C.I.)	Estimated abstinence rate (95% C.I.)
No intervention	3	1.0	6.7
Clinician training	3	1.6 (1.2-2.2)	10.5 (8.1-13.5)

Select for the articles used in the Update's meta-analysis.

It may be in the best interests of insurance companies, MCOs, purchasers, and governmental bodies within a specific geographic area to work collaboratively to ensure that tobacco dependence interventions are a covered benefit and enrollees are aware of these benefits. This would allow the financial benefits of the successful use of these services to be realized by all the health plans within a community.

Future Research

• Impact of promotion or communication of tobacco dependence treatment benefits on utilization and resulting population health and economic effects.
• Cost-effectiveness of specific elements of tobacco dependence treatment.
• Appropriate level of payment needed to optimize clinician delivery of tobacco dependence treatment.

Return to Contents

Systems Change: Cost Effectiveness

Tobacco use treatments are not only clinically effective, but they are cost-effective as well. Tobacco use treatments ranging from clinician advice to medication to specialist-delivered intensive programs are cost-effective in relation to other medical interventions such as treatment of hypertension and hyperlipidemia and to other preventive interventions such as periodic mammography.^194,221-224 In fact, tobacco use treatment has been referred to as the "gold standard" of health care cost effectiveness.²²⁵ Tobacco use treatment remains highly cost-effective, even though a single application of any effective treatment for tobacco dependence may produce sustained abstinence in only a minority of smokers. Finally, evidence-based tobacco dependence interventions produce a favorable return on investment from the perspective of both the employer and health plan due to reduced health care consumption and costs.^226-228 The cost-effectiveness of guideline recommendations for tobacco use treatment is addressed in detail in Chapter 6.

New Recommendations in the PHS-Sponsored Clinical Practice Guideline—Treating Tobacco Use and Dependence: 2008 Update

Guideline Availability

Return to Contents

Current as of September 2009

---

Internet Citation:

Systems Change: Treating Tobacco Use and Dependence. Based on the Public Health Service (PHS) Clinical Practice Guideline—2008 Update. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/clinic/tobacco/systems.htm

---