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Cost-effectiveness of the Clinical Practice

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					Cost-effectiveness of the Clinical Practice
Recommendations in the AHCPR
Guideline for Smoking Cessation
Jerry Cromwell, PhD; William J. Bartosch, MPA; Michael C. Fiore, MD, MPH;
Victor Hasselblad, PhD; Timothy Baker, PhD

   Context.\p=m-\The
                                           Agency for Health Care Policy and Research (AHCPR) pub-                          TOBACCO       use has been cited as the
lished the Smoking Cessation: Clinical Practice Guideline in 1996. Based on the                                             chief avoidable cause of death in the
results of meta-analyses and expert opinion, the guideline identifies efficacious in-                                       United States, responsible for more than
terventions for primary care clinicians and smoking cessation specialty providers.                                          420000 deaths annually.1 Despite this,
    Objective.\p=m-\To                     determine the cost-effectiveness of clinical recommendations in                  physicians and other practitioners fail to
                                                                                                                            assess and counsel smokers consistently
AHCPR's guideline.                                                                                                          and effectively.2"4
    Design.\p=m-\The                      guideline's 15 recommended smoking cessation interventions                           This study analyzes the cost-effective¬
were analyzed to determine their relative cost-effectiveness. Then, using decision                                          ness ofthe Agency for Health Care Policy
probabilities, the interventions were combined into a global model of the guideline's                                       Resource's (AHCPR's) Smoking Cessa¬
overall cost-effectiveness.                                                                                                 tion: Clinical Practice Guideline.2 Re¬
    Patients.\p=m-\The
                                           analysis assumes that primary care clinicians screen all pre-                    leased in April 1996, the guideline was
senting                        adults for smoking status and advise and motivate all smokers to quit dur-                   developed over a 2-year period by a panel
ing the course of a routine office visit or hospitalization. Smoking cessation inter-                                       of smoking cessation specialists using ex¬
ventions are provided to 75% of US smokers 18 years and older who are assumed                                               tensive quantitative analysis of published
to be willing to make a quit attempt during a year's time.                                                                  effectiveness data. Recommendations in¬
    Interv ntion.\p=m-\Thre                                                                                                 clude screening all presenting patients
                                                 counseling interventions for primary care clinicians and 2                 for tobacco use, advisingpatients who use
counseling interventions for smoking cessation specialists were modeled with and                                            tobacco to quit, and providing interven¬
without transdermal nicotine and nicotine gum.                                                                              tions that appear most efficacious. The
    Main Outcome Measure.\p=m-\Cost                          (1995 dollars) per life-year or quality-adjusted               recommendations were based on rigor¬
life-year (QALY)                         saved, at a discount of 3%.                                                        ous logistic regression meta-analyses of
    Results.\p=m-\The                     guideline would cost $6.3 billion to implement in its first year. As              various cessation intervention outcomes,
a result, society could expect to gain 1.7 million new quitters at an average cost of                                       ranging from self-help materials to mul-
$3779 per quitter, $2587 per life-year saved, and $1915 for every QALY saved.                                               tisession group counselinglasting several
Costs per QALY saved ranged from $1108 to $4542, with more intensive interven-                                              hours or more. Recommendations were
tions being more cost-effective. Group intensive cessation counseling exhibited the                                         targeted specifically to 3 audiences: pri¬
lowest cost per QALY saved, but only 5% of smokers appear willing to undertake                                              mary care clinicians; cessation specialists;
                                                                                                                            and administrators, insurers, and pur¬
this type of intervention.                                                                                                  chasers of health care services.
    Conclusions.\p=m-\Compared                         with other preventive interventions, smoking cessa-                     Formulation of optimal health care
tion is extremely cost-effective. The more intensive the intervention, the lower the                                        policy requires an analysis of the costs of
cost per QALY saved, which suggests that greater spending on interventions yields                                           recommended interventions relative to
more net benefit. While all these clinically delivered interventions seem a reason-                                         their clinical effectiveness. This informa¬
able societal investment, those involving more intensive counseling and the nico-                                           tion is not readily available in the case of
tine patch as adjuvant therapy are particularly meritorious.                                                                the AHCPR's guideline. Few claims
                                                                                       JAMA. 1997;278:1759-1766             data exist to quantify current practice.
                                                                                                                            Most counseling services are an integral
                                                                                                                            part of physician-patient contacts with
  From Health Economics Research, Inc, Wal-               and/or speaking for SmithKline Beecham pharmaceu-                 no separate billing, while other services,
tham, Mass (Dr Cromwell and Mr Bartosch); the             tical company. Prior to 1994 (when work on the Guide-             such as nicotine replacement and inten¬
Center for Tobacco Research and Intervention              line began), Drs Baker and Fiore had worked on clinical
(Drs Fiore and Baker), Section of General Internal        research studies funded in part by ALZA Corp, CIBA\x=req-\        sive counseling, are generally not cov¬
Medicine, Department of Medicine (Drs Fiore and           Geigy Corp, Elan Pharmaceutical, Lederle Laborato-                ered by insurance and, hence, do not pro¬
Baker), Comprehensive Cancer Center (Dr Fiore),           ries, Glaxo Wellcome, SmithKline Beecham, and                     duce a claims trail.
and   Department of Psychology (Dr Baker),                Hoechst Marion Rousel Inc. Prior to 1994, Dr. Fiore had
University of Wisconsin Medical School, Madison;          received honoraria for educational activities from CIBA\x=req-\      Finally, the benefits of stop-smoking
and the Center for Health Policy Research and             Geigy, Elan, Lederle, Marion Merrell Dow Inc, and                 treatments may be difficult to assess ac¬
Education, Duke University, Durham, NC (Dr                Parke-Davis.                                                      curately. The immediate effect of effica¬
Hasselblad).                                                 The statements contained in this article are solely
  Since publication of the AHCPR Smoking Cessation        those of the authors and do not necessarily reflect the           cious treatment is smoking cessation, and
Clinical Practice Guideline in April 1996, Dr Fiore has   views or opinions of the Agency for Health Care Policy            this may or may not be related to imme¬
done consulting, received funding for clinical research   and Research.                                                     diate health benefits. Even when cessa¬
studies, and/or spoken on behalf of GlaxoWellcome,           Reprints: Jerry Cromwell, PhD, Health Economics                tion leads to health benefits, these ben¬
SmithKline Beecham, and McNeil pharmaceutical             Research, Inc, 300 Fifth Ave, Sixth Floor, Waltham, MA
companies. Dr Baker has done consulting, research,        02154 (e-mail: jcromwell@her-cher.org).                           efits are delayed many years, occurring

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through decreased morbidity or mortal¬            Aggregating across interventions, the        sician: (1) minimal, (2) brief, (3) full, (4)
ity across a wide range of illnesses. Many     overall cost-effectiveness of the guide¬        individual intensive, and (5) group inten¬
studies" have found single smoking ces¬        line can be expressed as the ratio of ex¬       sive. The level of pro vider time and num¬
sation interventions to be cost-effective.     pected total guideline costs and ex¬            ber of sessions vary widely among these
However, these studies do not provide          pected benefits, eg, number of quitters         5 options. The first 3 interventions in¬
cost-effectiveness data on the range of ef¬    or QALYs saved. Expected interven¬              volve primary care clinicians, assumed
fective interventions that are both in cur¬    tion costs include the total fixed screen¬      to be physicians, while intensive coun¬
rent use and recommended for clinical          ing, advice, and motivation costs, which        seling is performed by smoking cessa¬
practice by the AHCPR.                         are assumed to be independent of which          tion specialists. Each of the counseling
                                               intervention is chosen, plus a weighted         options was analyzed both by itself and
                                               sum of the direct costs per intervention        in conjunction with nicotine replacement
METHODS
                                               for smokers selecting 1 of the 15 inter¬        (transdermal nicotine and nicotine gum).
General Approach                               ventions. Expected benefits are a
   The cost estimates developed in this        weighted sum of smokers' expected mar¬          Time Inputs
study were not based on individual pa¬         ginal quit rates across all interventions,         The assumptions that we made con¬
tients. Instead, they were based on rec¬       multiplied by QALYs saved per quitter,          cerning the providers and length of time
ommended resource inputs found in the          using patient intervention preference           required for each intervention scenario
guideline report. Similarly, estimates ofthe   proportions as weights. For example, if         are outlined in Table 1. The guideline
marginal effectiveness of interventions        three quarters of adult Americans who           recommends that health professionals
were taken from the guideline and were         smoke (25% of US adults are smokers)            screen all adult patients (aged 18 years
based on prospective clinical trial results.   are willing to try to quit during a year,       or older) for smoking status during each
   Two general methodological ap¬              and 40% of them prefer particular inter¬        office visit or hospitalization. We as¬
proaches were taken, both incorporat¬          vention, then 15 million persons could be       sumed that this task is performed by a
ing a societal perspective. Under one ap¬      expected to incur the guideline's estima¬       registered nurse (RN) and that it re¬
proach, three quarters of all smokers          tions for the direct costs associated with      quires 1 minute of provider time.
were assumed to undertake a particular         this intervention (ie, approximately 200           Following the identification of a
intervention during a year's time. This        million adult Americans X 0.25 X 0.75 X 0.4).   smoker, initial smoking cessation ad¬
represents the approximate percentage          Similarly, if a particular intervention is      vice is provided by physicians in either
of current US smokers who have made a          found to raise the underlying natural quit      an office or a hospital setting. This task
previous quit attempt.8 This answers the       rate by 0.1, then 1.5 million new quitters      involves delivering a clear, strong, and
question, "What would be the cost-effec¬       could be anticipated to justify the extra       personalized message urging every
tiveness of the guideline if all willing       costs. When weighted and summed across          smoker to quit. We assumed that this
smokers could be encouraged to under¬          all interventions, the result is an aver¬       would take 1 minute of physician time and
take 1 of the 15 interventions recom¬          age cost-effectiveness ratio for the en¬        that all smokers would be advised to quit
mended by the guideline panel?" When           tire guideline. A lower cost-effective¬         at each of their office visits or sometime
the resulting 15 cost-effectiveness ra¬        ness ratio is better, implying less cost        during the course of their hospitaliza¬
tios are compared across all cessation in¬     outlay per quitter or QAL Y saved. Hold¬        tion. Patients unwilling to quit after re¬
terventions, this informs policymakers         ing everything else constant, a higher          ceiving initial advice are provided with
as to which interventions appear to be         marginal quit rate would lower the over¬        a  motivational intervention that in¬
the most cost-effective.                       all cost-effectiveness, which would be          volves an additional minute of physician
   Under the second scenario, panel ex¬        lower, too, if smoker preferences shifted       time. We assumed all smokers would re¬
perts were queried regarding the likeli¬       to more efficacious interventions.              quire a motivational intervention dur¬
hood of patients choosing 1 of the 5 coun¬
                                               Patient Intake                                  ing at least 2 annual office visits or dur¬
seling interventions with or without nico¬                                                     ing the course of hospitalization.
tine replacement. These probabilities             The guideline recognizes 2 loci of pa¬          Minimal, brief, and full counseling in¬
were used to weight the costs and quit         tient intake: the office and the hospital.      terventions are provided to smokers
rates of the interventions. The result was     Interventions in each ofthese sites were        willing to make a quit attempt. These
a combined global cost-effectiveness ratio     analyzed separately and then combined           are delivered by primary care clinicians
for the guideline as a whole, which an¬        into a single cost-effectiveness ratio.         and involve increasing amounts of
swers the question, "How much would the        Screening, advice, and motivation costs,        physician time. Among these 3 interven¬
guideline likely cost per life-year saved or   which are incurred repetitively during          tions, full counseling involves the
quality-adjusted life-year (QALY) if           several annual office visits, were added        greatest amount of physician time—
adopted by practitioners, given the ex¬        to similar screening costs of hospitalized      15 minutes during an initial visit with
pected preferences of smokers for differ¬      patients. Direct intervention costs of          two 10-minute follow-up visits. When
ent interventions?"                            hospitalized patients were debited from         nicotine replacement is used, an extra 3
                                               those incurred by ambulatory patients.          minutes was allocated to the minimal,
Calculation of                                 This avoids double counting such costs,                  and full
Cost-effectiveness Ratios
                                                                                               brief,         counseling interventions
                                               as only 1 quit attempt was assumed dur¬         to account for the time  required to pre¬
   A cost-effectiveness ratio for a spe¬       ing a year's time regardless of whether a       scribe the pharmacotherapies and in¬
cific smoking cessation intervention can       smoker was an inpatient.                        struct patients in their use.
be decomposed into 4 components: (1)                                                              The individual intensive and group in¬
the cost of physicians screening the US        Identification of Direct Interventions          tensive counseling interventions begin
patient population; (2) the cost of physi¬       The amount of counseling that smok¬           with screening and advising tasks
cians advising smokers; (3) motivating         ers receive depends largely on patient          performed by primary care clinicians. Pa¬
unwilling smokers to try and quit; and,        and/or physician preferences. Based on          tients are then referred to a smoking
(4) the direct intervention costs incurred     the guideline, we modeled 5 possible            cessation specialist. We assumed that
in helping smokers quit, expressed per         counseling options that a patient may           smokers undergoing an individual inten¬
quitter or per life-year saved.                choose after receiving advice from a phy-       sive intervention receive 5 counseling ses-

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sions that are each 30 minutes long. The         Table 1.—Resource Utilization         Assumptions*
first session involves 10 minutes of                                                                                                 Intervention         Time, min
physician time for the purpose of assess¬
ing the patient and prescribing pharma-                        Interventions                               Minimal                                Brief                            Full
cotherapy and an additional 20 minutes of             forPrimary Care Clinicians                         Counseling                         Counseling                        Counseling
time with an RN. The remaining time is           Screening for tobacco use
divided between an RN with health edu¬              Registered nurse
                                                 Advice to quit
cation experience and a psychologist                Physician alone
(three 30-minute visits for the former and       Initial cessation counseling
two 30-minute visits for the latter). Across        Physician alone
the 5 sessions, there is a total of 10 min¬         Physician with patch or gum                                                                     10
utes of physician time, 80 minutes of RN         Follow-up counseling
                                                      First follow-up physician visit                            3-6
time, and 60 minutes of psychologist time.            Second follow-up physician visit                                                                                             10
We assumed that group intensive coun¬
                                                                                                                                                 Intervention      Time, mint
seling is delivered to groups of 10 pa¬
tients over 7 sessions that are each 1 hour                 Intensive Interventions                                            Individualt
long. Under this scenario, a physician is        for Smoking Cessation Specialists                                              Intensive
also available for a portion of the first ses¬   Screening for tobacco use
sion (in this case, 20 minutes). The remain¬       Registered nurse
                                                 Advice to quit
ing time for the first group session and ses¬      Physician
sions 2 through 7 involves an RN and a           Cessation counseling sessions
psychologist. These 2 professionalsjointly         Physician                                                                         10                                              20
provide services, and each contributes             Registered nurse                                                                  80                                             400
a   total of 400 minutes of time across all                                                                                          60                                             400
                                                   Psychologist
                                                      *Data from Fiore et al.2
                                                      fPatients referred to a smoking cessation specialist are first screened          in        office        hospital setting and advised
Input Costs                                      to    quit by a primary care clinician.
                                                                                                                                            an            or


  Physicians    are the most costly pro¬              tCounseling   time for "individual intensive"   patients   are   distributed   over   five 30-minute sessions.
vider group among primary care clini¬                 ¿Counseling time for "group intensive" patients are distributed over seven 1-hour sessions.
 cians. Their costs include not only a re¬
turn to their own time input but also any           We used estimates from the US Bu¬                                   over a period of 8 weeks. We used the 1995
 overhead costs associated with maintain¬        reau  of Labor Statistics for mean weekly                              average wholesale price as an estimate of
ing their practice. Other studies5 have          earnings to calculate the per minute cost                              the cost ofnicotine replacement.10 The av¬
used physician charges, but very few pa¬         of RN and psychologist time. In 1995, the                              erage cost of an 8-week supply ofthe patch
tients or insurers pay full charges today.       average weekly earnings of RNs and psy¬                                is $219.23. Nicotine gum is available un¬
Medicare rates were used instead, under          chologists were $729 and $698, respec¬                                 der 1 brand name in 2-mg or 4-mg doses.
the assumption that they more accurately         tively. Assuming that these professionals                              Both doses come in boxes of 96, and the
reflect the physician's true marginal cost       work an average of 40 hours each week,                                 average wholesale price per box is $38.85
of providing an office visit. To determine       the per minute labor cost of RNs is $0.30,                             and $63.29, respectively. We assumed
the per minute cost of physician time for        and for psychologists, the per minute la¬                              that patients use nicotine gum for the first
the initial intervention, per patient 1994       bor cost is $0.29. To account for additional                           3 months of their quit attempt and chew
Medicare allowed charges for 10-, 20-, 30-,      fringe and overhead costs, we doubled                                  an average of 10 pieces per day. This re¬
45-, and 60-minute visits were calculated        their salaries. Medicare physician claims                              quires a single patient to purchase 10
based on Current Procedural Terminol¬            already include a practice cost allowance                              boxes of gum. Therefore, complete treat¬
 ogy (CPT) codes for new patients receiv¬        and were not adjusted further.                                         ments with 2-mg gum and 4-mg gum cost
ing services in an office or another outpa¬         The guideline recommends that pa¬                                   $388.50 and $632.90, respectively.
tient setting. They were then adjusted           tients receive educational materials dur¬                                 Only a portion of patients willing to
for medical services inflation through           ing the course oftheir smoking cessation                               undergo an intervention quit success¬
1995. Next, a per minute cost was calcu¬         intervention. While physicians and hos¬                                fully. We assumed unsuccessful quitters
lated for each office visit code using the       pitals often receive self-help pamphlets                               would purchase only a 4-week supply of
specified time intervals and a weighted          from government agencies or antismok¬                                  the patch or gum. For transdermal nico¬
average taken across visit types to ac¬          ing groups free of charge, there is a cost                             tine, the average cost for the first month
count for differences in patients with re¬       associated with these materials that is                                of patches is $114.38. A 4-week supply of
spect to length of visit.  ·
                                                 incurred by society at large. For each                                 nicotine gum requires approximately 3
    Based on this approach, we estimated         intervention scenario, we assumed that                                 boxes of gum at a cost of $116.55 for 2-mg
that the Medicare effective physician al¬        patients would receive 2 educational                                   gum or $189.87 for 4-mg gum.
lowable charge per minute for an initial         pamphlets during their counseling ses¬
visit was $1.97 in 1995. Using the same          sion at a total societal cost of $2.00 per                             Resource Costs
method, we estimated that the average            patient per intervention.                                              by Intervention Activity
per minute cost of physician time for fol¬          The guideline recommends that provid¬                                 Table 2 displays our cost estimates of
low-up office visits was $2.20. We used the      ers offer nicotine replacement therapy to                              the guideline's recommended smoking
CPT codes for subsequent hospital care to        all smokers except in special circum¬                                  cessation interventions. These estimates
estimate initial physician advice and coun¬      stances, eg, pregnant women. Guideline                                 assume that patients first encounter a
seling costs in a hospital setting, ie, $1.92    recommendations were followed on the                                   physician during the course of a routine
per minute. We assumed that hospital¬            amount and dosages that each patient                                   office visit. All the interventions have the
ized patients would receive follow-up af¬        should receive." A complete smoking ces¬                               samecostper participant for preinterven-
ter discharge in an office or outpatient set¬    sation intervention using the patch re¬                                tion screening ($0.60), advice ($1.97), and
ting at the same $2.20 cost per minute.          quires that patients use different dosages                             motivation ($1.97). Per participant direct

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Table 2.—Smoking Cessation Costs per Participant*           tients. Adding a complete treatment of          analyses to the entire US smoking popu¬
                                          Total Cost
                                                            transdermal nicotine increases intensive        lation, the ORs derived from the analyses
                                        per Participant     counseling costs to $323.73 for individual      were applied to the underlying 3-month-

    Cessation Intervention
                                       I-1
                                       Successful Failed
                                                            counseling and $272.37 for group coun¬          or-more quit rate of all smokers (ie, all¬
                                                            seling, respectively. A complete, suc¬          comers) in the United States. We as¬
Without nicotine replacement                                cessful intensive intervention with nico¬       sumed this rate was 5% (vs 5.7% for smok¬
 Minimal counseling                       14.51     14.51
                                          37.79     37.79
                                                            tine gum costs $493 when provided               ers  quitting for at least 1 month).11
  Brief counseling
  Full counseling                         75.55     75.55
                                                            through individual counseling and                  To illustrate our method, the estimated
  Individual intensive                   104.50    104.50
                                                            $441.64 when provided in a group con¬           OR for brief counseling was 1.4, implying
                     counseling                             text. Again, among the scenarios that
  Group intensive counseling              53.14     53.14
                                                                                                            roughly a 40% gain in quitters. Using the
                                                            use pharmacotherapy, costs would be             most conservative ORs for the patch (2.1),
With transdermal nicotine
  Minimal counseling                     246.25    141.40   substantially less for patients who fail.       the combined OR for brief counseling
  Brief                                  262.93    158.08
                                                                                                            with the patch is 2.94 (ie, 1.4x2.1). Mul¬
        counseling                                          Effectiveness of Smoking
  Full counseling                        300.69    195.84
                                                            Cessation Interventions
                                                                                                            tiplying the underlying 5% quit rate by
  Individual intensive    counseling     323.73    218.88                                                   2.94, after converting it into an OR (0.05/
  Group    intensive   counseling        272.37    167.52
                                                               The guideline uses long-term quit rates      0.95=0.0526), results in an estimated OR
                                                            as its effectiveness indicator. Primarily us¬   of 0.155. Converting this OR back into a
With nicotine gum
  Minimal counseling                     415.52    143.57   ing a modified intent-to-treat analysis         percentage quit rate equals 0.134 (ie,
  Brief counseling                       432.20    160.25   technique, the researchers who support          0.155/[1+0.155]). Finally, subtracting the
  Full   counseling                      469.96    198.01
                                                            the guideline panel drew from peer-             underlying 5% quit rate gives 8.4% as the
  Individual intensive
                     counseling          493.00    221.05   reviewed, published clinical trial litera¬      marginal quit rate of brief counseling us¬
  Group intensive counseling             441.64    169.69
                                                            ture based on at least 5 months of follow-      ing the patch as adjuvant therapy. This is
                                                            up data to calculate percentages of             a more conservative estimate than one
  *AII costs reported in 1995 dollars. Data from Fiore et   individuals who successfully quit smok¬         based on the average quit rate of the con¬
aP; 1996 Physician's GenRX"; Medicare allowed                                                               trol groups in the clinical trials. Using the
changes; the Current Population Survey: 1995 Estimates      ing using different interventions. Meta-
of Weekly Earnings, published in 1996 by the US Bureau      analyses evaluated basic treatment char¬        8.8% baseline would have produced al¬
of Labor Statistics; and 1994 Medicare Part data.           acteristics such as counseling format (eg,      most 60% more quitters.
                                                            individual vs group), duration of treat¬           Sensitivity analysis (discussed below)
intervention costs naturally increase with                  ment, and use of pharmacotherapy. Stud¬         was    also applied to the percentage of
the intensity of counseling provided. The                   ies that included the same intervention         smokers willing to make a quit attempt
estimated cost of a single minimal coun¬                    were grouped together, screened to en¬          during the year. To recognize that not all
seling intervention without pharmaco-                       sure methodological rigor, and analyzed         quitters stay abstinent, a 45% relapse rate
therapy is $14.51. The initial intervention                 using either fixed or random effects lo¬        is applied as well to the marginal quit
takes 3 minutes and costs $5.91 of physi¬                   gistic models. The guideline odds ratios        rates.12 The 45% figure is based on consid¬
cian time. A 3-minute follow-up (provided                   (ORs), which indicate an intervention's         erable relapse data showing that most re¬
via telephone) by a physician costs $6.60.                  marginal effectiveness, are generated by        lapses typically occur within the first 6
Finally, education materials cost $2.00.                    exponentiating the logistic regression co¬      months.13 Therefore, this figure estimates
The brief intervention assumes a longer                     efficients obtained from 56 studies in the      the relapse rate for subjects who have al¬
initial physician visit and follow-up time,                 meta-analyses.                                  ready passed the time of maximal relapse
with a per participant cost of $37.79. The                     From the meta-analyses, the average          risk. Long-term follow-up data show that,
full counseling intervention, requiring 15                  baseline "no intervention" quit rate was        of subjects who have been abstinent for 1
minutes of physician time during the ini¬                   8.8% vs 10.7% for minimal counseling,           year, only some 30% or so will relapse over
tial visit plus two 10-minute follow-up vis¬                12.1% for brief counseling, and 18.7% for       the subsequent 5 years.8 After 5 years re¬
its, costs $75.55.                                          full counseling lasting more than 10 min¬       lapse occurs, but the rate is extremely
   Adding pharmacotherapy greatly in¬                       utes, all excludingpharmacotherapy. The         low.8·12 Also, after prolonged abstinence,
creases intervention costs. For brief                       baseline and intervention quit rates for        the rate of relapse is approximately bal¬
counseling, the per participant cost rises                  intensive counseling (4-7 sessions) were        anced by cessation occurringthrough sub¬
to $262.93 with the addition of transder¬                   10.4% and 22.6%, respectively. Baseline         sequent quit attempts.8
mal nicotine and to $432.20 with nicotine                   quit rates vary by intervention owing to
gum. Full counseling with complete                          different samples and "self-help" activi¬       Quality-Adjusted Life-Years Saved
transdermal nicotine treatment costs                        ties among the various control groups in           The guideline does not differentiate in¬
$300.69 vs $469.96 with nicotine gum.                       the clinical trials. Odds ratios for the        terventions by patient age. All smokers,
These costs, however, are much lower                        patch and gum over and above counseling         regardless of age, are deemed candidates
for patients who fail to quit because they                  alone were found to range between 2.1 to        to try to quit. Moreover, the clinical trial
do not require complete treatment with                      2.6 and 1.4 to 1.6, respectively. Interven¬     results do not differentiate quit rates by
nicotine replacement.                                       tion-specific marginal quit rates were de¬      intervention by age group. Quit rates
   Intensive interventions are divided                      rived by subtracting the underlying base¬       were applied uniformly to the age- and
into 5 sessions for individual counseling                   line quit rate.                                 sex-specific distribution of smokers and
and 7 sessions for group counseling. The                       Despite statistically controlling for        then were converted into years of life
cost of educational materials and phar¬                     "all-comers" vs "want-to-quit" subjects,        saved using published and unpublished
macotherapy is assumed to be the same                       the logistic coefficients estimated from        estimates developed by Fiscella and
under these scenarios. While the group                      the meta-analyses generated unreason¬           Franks.6 The authors calculated sex- and
counseling sessions are longer than in¬                     ably high baseline quit rates (eg, 8.8%) for    age-specific years of life saved using life
dividual counseling sessions (1 hour as                     2 reasons: many studies include only            expectancy data for smokers and never
opposed to 30 minutes), their per par¬                      want-to-quit subjects, and some control         smokers taken from Rogers and Powell-
ticipant costs ($53.14 per patient) are                     subjects receive very low-intensity             Griners.14 Fiscella and Franks6 extrapo¬
much lower because the cost for each                        cessation interventions (eg, self-help ma¬      lated mortality rates for smokers vs never
group session is distributed across 10 pa-                  terials). To apply the results of the meta-     smokers using a 20-year phase-in period

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based   on mortality ratios of long-term        Table3.—Expected Annual Number of Quitters and Life-Years Saved by Smoking Cessation Intervention,
quitters to never smokers derived from          Assuming 75% of Smokers Attempt to Quit Once During the Year*
the American Cancer Society's Cancer                                                                                         Overall Guideline
Prevention Study II.8 They also made a
quality-of-life adjustment to the raw                                                                                Quitters,t
                                                                                                                                          Life-Years
                                                                                                                                          Saved.*.
                                                                                                                                                            Quality Life-
                                                                                                                                                           Years Saved.§
years-of-life-saved figures using an index                                                     Marginal               No. in               No. in              No. in
of years of healthy life constructed from                Interventions                       Quit Rate, %           Thousands            Thousands          Thousands
questions on the National Health Inter¬         Minimal counseling alone                          0.94                  189                  276                373
view Survey (NHIS).3·15                           With patch                                      6.70                  1347                1968
   Assuming that marginal quit rates ap¬          With gum                                          3.68                  734               1072               1448
ply uniformly to all age groups, an overall     Brief counseling alone                              1.86                  374                546                738
estimate of life-years saved was derived          With patch                                        8.40               1689                 2467               3333
by weightingexpected years saved within           With gum                                          4.95                  995               1454               1964
age group by the actual distribution of         Full counseling alone                                                  1247                 1821               2460
smokers by age group and by the uniform           With patch                                                           3217                 4700               6348
quit rate. Men aged 25 to 29 years are ex¬        With gum                                         10.90               2192                 3202               4325
pected to gain 1.31 years of life, discounted   Intensive counseling alonell                        6.62               1331                 1945               2627
at 3%, which is equivalent to 2.34 QALYs.         With patch                                                           3346                 4888               6602
Older men, aged 65 to 69 years, only save         With gum                                         11.50               2312                 3378               4563
0.47 years of life (0.69 QALYs). Women          Combined intervention^                                                 1669                 2439               3294
gain more years of life from quitting than
men. Female quitters aged 25 to 29 years          *Data from Fiore et al2 and Fiscella and Franks.6 Ellipses indicate not applicable.
                                                  tThe   number of   quitters   was   discounted   by   45% to account for   post-follow-up relapse.
save 1.43 life-years (1.94 QALYs), while
                                                  ^Life-years (discounted 3%) were derived using a distribution of smokers and adjustment factor saved for each
                                                                                                    1.46 adjustment factor. The                  represents the
those aged 65 to 69 years save 1.41 life-       average life-yearssaved                 the current
                                                                        per quitter given                                                expected life-years
                                                sex-specific age group.
years (1.08 QALYs). Given the current             §Quallty-adjusted life-years (discounted 3%) were derived using a 1.97 adjustment factor. The adjustment factor
distribution of smokers, we calculated a        represents the average life-years saved per quitter given the current distribution of smokers and expected quality-
weighted average of 1.46 life-years saved       adjusted life-years saved for each sex-specific age group.
                                                   HDifferent quit rates were not available for "individual counseling" vs "group intensive counseling". Therefore, the
per quitter (1.97 QALYs). Our analysis          same quit rate (6.62%) was used for both interventions.
(and the analysis of Fiscella and Franks")        IfThe variable was derived by weighting the individual interventions by the likelihood of smokers choosing each
                                                intervention.
assumes a 3% discount rate for life-years
saved. Sensitivity analyses were per¬           75% estimate reflects the total percent¬                           rate  (after 5 months of abstinence) was
formed at 0% and 5%.                            age ofsmokers who will try to make a quit                          also tested at 35% and 55% in some simu¬
   Table 3 shows the intervention's mar¬        attempt in a given year and reflects the                           lations.
ginal quit rates, expected number of quit¬      increase in cessation attempts caused by
                                                                                                                   Basic Parameters
ters, and life-years and QALYs saved for        introduction of the guideline interven¬
each of the guideline interventions. If in¬     tions (eg, brief interventions offered                                Each of the smoking cessation sce¬
tensive counseling with transdermal nico¬       across diverse health care settings).                              narios that we modeled is based on a
tine were provided to three quarters of         Based on the expert opinion of the guide¬                          common set of basic parameters. As of
smokers in the United States willing to         line panel, we assumed that 40% of smok¬                           January 1, 1996, the US resident popu¬
try to quit during a year's time, it would      ers would choose brief counseling, 30%                             lation older than 18 years was estimated
generate the largest number of quitters,        would choose full counseling, 25% would                            by the US Bureau of the Census at 195
3346000 (6602000 QALYs). Minimal                choose minimal counseling, and 5% would                            million. The probability of smoking is
counseling without pharmacotherapy re¬          choose intensive counseling (2.5% indi¬                            based on the NHIS, which found that, in
sults in the fewest quitters, 189000            vidual intensive counseling and 2.5%                               1993, 25% of the US adult population
(373 000 QALYs). Based on patient pref¬         group intensive counseling). We further                            smoked cigarettes.16 We assumed that
erences for the various interventions (dis¬     assumed that 75% of all smokers who are                            the proportion of the population who
cussed next), adoption of the guideline         willing to try to quit, regardless of the                          smoked remained constant between
could be expected to generate 1.67 million      length of counseling they choose, would                            1993 and 1996, producing approximately
additional quitters and nearly 3.3 million      use pharmacotherapy. Among those will¬                             48 745 000 adult smokers in 1996.
QALYs, discounted at 3% (Table 3).              ing to use pharmacotherapy, 83% would                                 Our estimate of the number of physi¬
                                                choose the patch and 17%, nicotine gum.                            cian office visits per year is based on the
Intervention Decision Probabilities             In our model, for example, 1.875%                                  National Ambulatory Medical Care Sur¬
   In actual practice, patients and provid¬     (0.25 x 0.75 x 0.40 x 0.25 x 100) ofthe entire                     vey.14 This study found that there was a
ers vary in their intervention preferences,     US population would undergo brief coun¬                            total of 606877000 office visits in the
and it is highly unlikely that all smokers      seling alone, 4.67% (0.25x0.75x0.40x                               United States in 1992 among the popu¬
would choose the same intervention.             0.75 x 0.83 x 100) would likely receive brief                      lation aged 15 years and older, resulting
While group intensive counseling costs          counseling and transdermal nicotine, and                           in 3.11 physician office visits per year
less per quitter than any of the other          0.96% (0.25 0.75 0.40 0.75 0.17 100)                               per adult.
interventions, very few patients would          would undergo brief counseling using                                  Smokers have higher physician office
actually choose this treatment option.          nicotine gum as adjuvant therapy. When                             and hospital utilization rates than people
Conditional probabilities incorporating         summed across the 15 interventions, the                            who have never smoked. Rice et al17
willingness to quit and preferences con¬        percentages add to the 18.75% of the en¬                           found that, on average, smokers experi¬
cerning format and use of pharmaco¬             tire US population who would be ex¬                                enced about 6% more physician office
therapy were calculated for the 15 inter¬       pected to undergo a quit attempt.                                  visits and spent 27% more days in the
ventions. Our baseline assumes that 25%            Sensitivity analysis of the decision                            hospital than never smokers. If the ratio
of the US adult population smokes1" and         probabilities involved testing the 75%                             of the average number of physician vis¬
that 75% of smokers would be willing to         rate of those who are willing to try and                           its among smokers vs nonsmokers is
make a quit attempt in a year's time. The       quit at 50% and 100%. The 45% relapse                              1.06, and the average number of visits

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Table 4.—Cost-effectiveness of          Smoking   Cessation   by   Intervention*                                    increases their marginal effectiveness
                                                                                                    Cost per        substantially. When using transdermal
                                                                              Cost per          Quality-Adjusted    nicotine (the patch) as adjunct therapy
                                                  Cost per               Life-Year Saved,          Life-Year        to each of the counseling interventions,
          Intervention                             Quitter                (3% Discount)          (3% Discount)      the cost per quitter ranged from $2310
Without nicotine replacement
                                                    7922                       5423                  4015
                                                                                                                    for group intensive counseling, which is
  Minimal    counseling
  Brief   counseling                                6276                       4296                  3181           slightly less cost-effective, to $4745 for
                                                                                                                    minimal counseling, which is far more
  Full   counseling                                 2989                       2046                  1515
                                                                                                                    cost-effective than it would have been
  Individual intensive counseling                  3595                        2461                  1822
                                                                                                                    without nicotine replacement. This trans¬
  Group intensive counseling                       2186                                               1108
                                                                                                                    lated to $1171 and $2405 per QALY, re¬
With transdermal nicotine
  Minimal counseling                               4745                        3248                  2405           spectively. The cost per quitter for coun¬
  Brief counseling                                 4184                                              2120           seling with nicotine gum ranged from
  Full                                                                         1859                  1376
                                                                                                                    $3596 for group intensive counseling to
          counseling
  Individual intensive counseling                  2871                        1969                  1455           $8962 for minimal counseling. The cost
                                                                                                      1171          per QALY ranged from $1822 to $4542,
 Group intensive counseling                         2310                       1581
With nicotine gum                                                                                                   respectively.
  Minimal counseling                                8962                       6135
                                                                                                                    Cost-effectiveness of
  Brief    counseling                               7350                                             3725
                                                                                                                    Combined Interventions
  Full    counseling                                                                                 2147
  Individual intensive                             4407                                              2233
                                                                                                                       Table 5 shows total costs, number of
                           counseling
  Group     intensive   counseling                 3596                        2461                  1822           quitters, life-years saved, and the ulti¬
                                                                                                                    mate cost-effectiveness of the combined
  *Data from Fiore et al2 and Fiscella and Franks.6 This table assumes that 75% of patients who smoke attempt
                   during the year. Quitters were discounted by 45% to account for relapse. All costs are in 1995
to quit at least once
                                                                                                                    smoking cessation guideline, derived by
dollars.                                                                                                            weighting each ofthe individual interven¬
                                                                                                                    tion's costs and benefits by the likelihood
                                                                                                                    of a smoker choosing it. For example, the
per   capita is 3.11, then the average                             RESULTS                                          total cost of minimal counseling without
smoker would experience 3.25 visits                                                                                 nicotine replacement is $93 578 727. This
while nonsmokers would average 3.06                                Cost-effectiveness of                            was derived by assuming that only 6.25%
visits. We estimated that 158580925                                Individual Interventions                         of smokers (0.25 X 0.25) would receive this
physician office visits were made by                                  Table 4 shows cost-effectiveness ratios       intervention. Direct intervention costs
smokers (3.25x48475000) in 1992.                                   for 15 smoking cessation interventions           would be $33105 235 vs $60 473 492 in to¬
   Using NHIS estimates of the distri¬                             that are described in the guideline. These       tal preintervention costs (screening, ad¬
bution of short-term hospital episodes by                          results were derived by assuming that            vice, and motivation). Minimal counsel¬
age and sex,18 we calculated that there                            75% of smokers would make 1 quit at¬             ing without pharmacotherapy would gen¬
were 29 051 900 admissions among the                               tempt during the year with all using a           erate 12 000 quitters under the combined
adult population aged 18 years or older                            particular intervention. Hence, the fig¬         guideline, 17000 life-years saved, and
of a total of 32 315 795 admissions, ex¬                           ures answer the question, "What would            23 000 QALYs saved.
cluding newborn and psychiatric, re¬                               be the guideline's cost-effectiveness if all        Overall, the average cost per quitter
ported by the American Hospital Asso¬                              willing-to-quit smokers undertook a              was $3779; the average cost per life-year
ciation (AHA) in its 1993 survey of                                single intervention?" Cost per quitter           saved, $2587; and the average cost per
hospitals.19 Therefore, there were ap¬                             amongthecounselinginterventions with¬            QALY saved, $1915.
proximately 0.149 admissions per adult                             out pharmacotherapy ranged from a low               Brief and full counseling with pharma¬
resident (29 051 900/194 980 000). We as¬                          of $2186 for group intensive counseling to       cotherapy are expected to generate the
sumed that because smokers experi¬                                 a high of $7922 for minimal counseling.          preponderance of both costs and ben¬
ence 27% more hospital days per year                               Cost per QALY (discounted at 3%) was             efits, in part because they are more
than nonsmokers,17 they would also be                              lower and therefore better, ranging from         costly and efficacious; but it is also be¬
27% more likely to be admitted to the hos¬                         $1108 for group intensive counseling to          cause they are among the most popular
pital. We calculated that 17.8% of smok¬                           $4015 for minimal counseling.                    choices for trying to quit, ie, 24.9% opt
ers would experience an inpatient stay                                As the amount of clinician time in¬           for brief counseling with the patch and
during the year, while only 13.9% of non-                          creases, intervention costs and the num¬         18.7% for full counseling with the patch.
smokers would be admitted, using the for-                          ber of quitters both increase while the             Based on the guideline and the likely
mula: (0.149 0.25X1.27XARNS
                          =                                        cost per quitter decreases (except for in¬       cessation intervention preferences of pa¬
+(0.75 x ARNS), where ARNS indicates                               dividual intensive counseling). Group in¬        tients, it would cost $6.3 billion annually
the estimated admission rate ofnonsmok¬                            tensive counseling is a particularly low-        to screen, motivate, and provide 75% of
ers. These estimates generated 8 653 757                           cost intervention, excluding patient time        ambulatory and hospitalized smokers
smoker admissions (0.178x48.7 million                              costs, even though it involves the great¬        with the intervention of their (expected)
smokers). However, among the general                               est amount of patient-clinician time             choice. Screening, advice, and motiva¬
population, only 80.5% ofadmissions are                            (seven, 1-hour sessions). This is because        tion account for $968 million, or 15.4%, of
unique hospital admissions, according to                           it generates a large number of new quit¬         the total cost. Implementation of the
NHIS estimates; the remaining 19.5% are                            ters because of its intensity of contact         guideline would result in 1.67 million new
readmissions. We calculated that the to¬                           and because intervention costs are               quitters during the first year, with more
tal number of unique smoker admis¬                                 shared across groups of 10 patients,             than 60% resulting from brief and full
sions eligible for an intervention would                           which lowers the cost per quitter even           counseling using the patch. The figure of
be 6 966 275, assuming each patient would                          further.                                         1.67 million new quitters is derived from
undergo a smoking intervention only once                             Adding pharmacotherapy increases               the 48.7 million smokers in the United
on an inpatient basis during a year's time.                        the cost of each intervention, but it also       States figure. We assumed that 36.6 mil-

                                                  Downloaded from jama.ama-assn.org by guest on May 7, 2011
lion ofthose smokers would make a new           Table 5.—Cost-effectiveness of the Combined           Agency   for Health Care    Policy   and Research Resource
                                                Guideline*
quit attempt during the year, generat¬
ing 3.03 million new quitters based on a                                                                                       Life-Years         Quality-Adjusted
combined intervention marginal quit                                                                        Quitters.t            Saved.$              Life-Years
rate of 8.3%. The guideline would cost an                                             Costs, $   in         No. in               No. in            Saved,§ No.     in
                                                       Interventions                  Thousands           Thousands           Thousands              Thousands
average of $3779 per quitter. The cost          Without nicotine replacement
per life-year saved (discounted at 3%)           Minimal counseling                       93 579                                                           23
would be $2587. Adjusting for improved           Brief counseling                        234 730                 37                 55                     74
quality of life further lowers the cost per       Full counseling                        279 425                 93                137                    184
life-year saved to $1915.                         Intensive counseling                    29 908                                     12                     16
                                                  Group counseling                                                                   12
Sensitivity Analysis                            With transdermal nicotine
   We performed a series of 1-way sensi¬          Minimal counseling                     998 787               210                 308                    415
tivity analyses on several of our major as¬       Brief counseling                     1766 540                                    617                    833
sumptions. Our baseline analysis assumes          Full counseling                      1 637972                603                 881
that 75% of smokers are willing to make a         Intensive counseling                   150 075                 52                 76                    103
quit attempt. When we assumed that only           Group counseling                       120 769                 52                 76                    103
50% of patients would be willing to try the     With nicotine gum
intervention of their choice, the cost per        Minimal counseling                     205 551                 23                 34                     45
QALY saved (discounted at 3%) in¬                 Brief counseling                      335 782                  50                 73                     98
creased from $1915 to $2073, or by 8.25%.         Full counseling                       348 209                 82                 120                    162
If we assumed that all smokers would be           Intensive counseling                    31843
willing to undergo an intervention, the           Group counseling                        25 981                                                           14
cost per QALY decreased further to              Combined interventions!!               6 307 337               1669               2439                   3294
$1836, or by 4.12% more. Altering the as¬
                                                  *Data from Fiore et al2 and Fiscella and Franks.6
sumption about the number of smokers              fThe number of quitters was discounted by 45% to account for post-follow-up relapse.
willing to try to quit has a slight impact on     ÍLife-years (discounted 3%) were derived using a 1.46 adjustment factor. The adjustment factor represents the
the cost-effectiveness ratios because pre¬      average life-years saved per quitter given the current distribution of smokers and expected life-years saved for each
intervention costs are unchanged, while         sex-specific age group.
                                                  §Quality-adjusted life-years (discounted 3%) were derived using a 1.97 adjustment factor. The adjustment factor
the number of quitters varies at the vari¬      represents the average life-years saved per quitter given the current distribution of smokers and expected quality-
ous  willing-to-quit rates.                     adjusted life-years saved for each sex-specific age group.
                                                   (This variable was derived by weighting the individual interventions by the likelihood of smokers choosing each
   The cost-effectiveness ratios proved         intervention.
 quite sensitive to the discount rate used
to adjust life-years saved. When QALYs          tients would travel an average of 1 hour                    effective than full counseling with 2
were discounted by 5%, the cost for the         (round-trip) for each visit. Patient time                   follow-up sessions, eg, $3446 per QALY
guideline was $3205 per QALY saved—             per intervention ranged from 3 minutes                      vs $1975 per QALY. Adding patient costs
or two thirds more; without any dis¬            for minimal counseling to 840 minutes for                   to the combined interventions in¬
counting, the guideline would cost only         group intensive counseling, ie, seven 1-                    creased overall cost per QALY from
$745 per QALY saved—61% less.                   hour sessions plus 7 additional travel                      $1915 to 2167 (13%).
   At press time, a new analysis by CDC         hours. According to the Bureau of Labor
estimated that the baseline, 3-month                                                                        COMMENT
                                                Statistics, in 1995, the median weekly sal¬
quit rate for smokers is 4.6% (C. Husten,       ary of full-time wage and salary workers                       These analyses demonstrate that full
MD, MPH, unpublished data, Novem¬               was $479. We assumed an average work¬                       implementation ofthe guideline through¬
ber 1997). We tested the sensitivity of         week was 40 hours long and calculated an                    out 1 year could cost $6.3 billion annually,
our combined model to the new baseline          average per minute patient opportunity                      or $32.31 per capita. For this investment,
and found that the cost per QALY in¬            cost of $0.20 ($479/2400 minutes). Group                    society could expect to gain approxi¬
creased to $2048, or 6.9%.                      intensive counseling involved the great¬                    mately 1.67 million new quitters over and
   The sensitivity ofthe relapse rate was       est amount of travel and direct interven¬                   above the current baseline 5% quit rate
tested at 35% and 55%. The lower re¬            tion time (seven 1-hour visits), costing                    after allowing for a 45% relapse rate
lapse rate decreased the guideline cost         each participant $168 in lost time for other                among those abstinent for 5 months from
per QALY to $1620 (a 15.4% decline).            activities.                                                 the day of cessation. These quitters could
Increasing the relapse rate to 55% raised          As the intensity of the interventions                    expect to enjoy 2.4 million extra life-years
costs per QALY by 22% to $2340, which           increases, they become more sensitive to                    (3.3 million extra QALYs), even after dis¬
is still a low figure.                          patient opportunity costs. Group inten¬                     counting by 3%. Given that smokers at all
   Treatments that involve more direct          sive counseling without pharmaco¬                           ages experience reduced life expectancy
intervention time and 1 or more follow-up       therapy experienced the greatest change                     and survival rates,26 certainly many
visits can have substantial patient costs.      in cost per QALY, rising from $1108 when                    younger quitters would enjoy more pro¬
For each intervention, we estimated the         patient costs were ignored to $3446 when                    ductive years of employment.
costs associated with patient travel and        they were included in the analysis, more                       For $2587, society could expect to save
cessation counseling time. Travel time for      than tripling the estimate. Still, minimal                  another life-year by implementing the
initial physician visits was excluded be¬       counseling and brief counseling without                     guideline. Given the negative health as¬
cause patients would have incurred these        pharmacotherapy remained less cost-                         sociated with smoking, the cost-effec¬
costs in the absence of the smoking ces¬        effective at $4132 and $3944 per QALY                       tiveness of the guideline is even better
sation intervention. Patient-specific time      saved, respectively. However, when pa¬                      on a QALY basis, ie, $1915. The more
costs associated with each smoking ces¬         tient costs were incorporated into the                      intensive the cessation intervention, the
sation intervention (including travel to        analysis of interventions without phar¬                     lower the cost per year of life saved.
follow-up or intensive counseling ses¬          macotherapy, group intensive counsel¬                       While all interventions seem a reason¬
sions) were calculated assuming that pa-        ing with 7 sessions became less cost-                       able societal investment, those involv-

                                  Downloaded from jama.ama-assn.org by guest on May 7, 2011
ing more intensive counseling and the          preventive interventions. Such issues are            5. Cummings SR, Rubin SM, Oster G. The cost\x=req-\
                                                                                                    effectiveness of counseling smokers to quit. JAMA.
nicotine patch are particularly meritori¬      certainly important in evaluating the net            1989;261:75-79.
ous. Nicotine gum with counselingis also       benefits of preventive interventions.                6. Fiscella K, Franks P. Cost-effectiveness of the
more effective than counseling alone, al¬         Relative to other medical interven¬               transdermal nicotine patch as an adjunct to physi-
though it does not generate as many new        tions, all the smoking cessation interven¬           cians' smoking cessation counseling. JAMA. 1996;
                                                                                                    275:1247-1251.
quitters as the patch.                         tions recommended in the guideline
                                                                                                    7. Oster G, Huse DM, Delea TE, Coldize GA. Cost\x=req-\
   A study like ours naturally has sev¬        appear cost-effective and should be pro¬             effectiveness of nicotine gum as an adjunct to phy-
eral limitations. Results reflect only the     moted. Tengs et al27 reviewed 500 life-              sicians' advice against cigarette smoking. JAMA.
first year of guideline implementation. It     saving interventions and adjusted them               1986;256:1315-1318.
is not at all clear how the success rates      for inflation (all costs are expressed in            8. US Dept of Health and Human Services. The
                                                                                                    Health Benefits of Smoking Cessation: A Report
of the various interventions would             1993 dollars), discount rate (all findings           From the Surgeon General. Atlanta, Ga: US Dept of
change, if at all, with repeated years of      converted to 5% discount rate), exclusion             Health and Human Services, Public Health Service,
the guideline. Clinical trials data were un¬   ofindirect costs, and consistent effective¬          Centers for Disease Control, Center for Chronic
available to build a dynamic, recurring in¬    ness measures (years of life saved).                 Disease Prevention and Health Promotion, Office
                                                                                                    on Smoking and Health; 1990. DHHS publication
tervention model.                                The costs of the AHCPR's guideline
                                                                                                    No. (CDC) 90-8416.
   Differences in marginal quit rates by       are $3539 per life-year saved when dis¬              9. The Smoking Cessation Clinical Practice Guide-
intervention with respect to age, sex, se¬     counted at a comparable 5% rate. Several             line Panel and Staff. The Agency for Health Care
verity of illness, and motivational level      well-targeted prevention strategies                  Policy and Research smoking cessation clinical prac-
                                               listed in the study by Tengs et al26 show            tice guideline. JAMA. 1996;275:1270-1280.
could not be determined through meta-                                                                10. 1996 Physician's GenRX: The Complete Drug
analysis because of small samples. How¬        very low cost-effectiveness ratios as well,          Reference. St Louis, Mo: Mosby\p=m-\Year Book Inc; 1996.
ever, our model uses a sex- and age-spe¬       including a 1-time screening for cervical             11. Centers for Disease Control and Prevention.
cific distribution of smokers when con¬        cancer   for   women    older than 64 years          Smoking cessation during previous year among
                                               ($2053) and pneumonia vaccination for                                   States, 1990 and 1991. MMWR
structing average life-years and QALYs                                                              adults\p=m-\United
                                                                                                    Morb Mortal Wkly Rep. 1993;42:504-507.
saved per quitter.                             people older than 64 years ($1769). Other            12. Gilpin EA, Pierce JP, Farkas AJ. Duration of
   Further, it is probably unrealistic to      screening strategies targeted at younger              smoking abstinence and success in quitting. J Natl
assume the same permanent marginal             age groups cost considerably more, in¬               Cancer Inst. 1997;89:572-576.
quit rate for all willing smokers who are      cluding an annual mammography for                    13. Cohen S, Lichtenstein E, Prochaska J, et al. De-
                                                                                                    bunking myths about self-quitting: evidence from
triaged through a single intervention.         women aged 40 to 49 years ($61744) and
                                                                                                    ten prospective studies of persons quitting smoking
Nevertheless, we believe the quit rates        hypertension screening for men aged 40               by themselves. Am Psychol. 1989;44:1355-1365.
give a reasonable guide to the relative        years ($23 335). The smoking cessation in¬           14. Rogers RG, Powell-Griner E. Life expectancies
advantages ofthe various interventions.        terventions are all the more remarkable              of cigarette smokers and non-smokers in the United
                                               in that the guideline is not targeted to any         States. Soc Sci Med. 1991;32:1151-1159.
   Followingprevious cost-effectiveness                                                             15. Adams PF, Benson V. Current estimates from
studies of smoking cessation interven¬         one population group.                                the National Health Interview Survey, 1991. Vital
tions,5·7 we excluded lifetime medical ex¬         The guideline's cost-effectiveness ratio         Health Stat 10. 1992;181:1-212.
penditures from our analysis. Whether          is favorable relative to most other medical          16. National Center for Health Statistics. Health
                                                                                                    United States, 1994. Hyattsville, Md: US Public
lifetime medical expenditures should be        interventions, confirming Eddy's28 treat¬            Health Service; 1995. Publication PHS 95-1232.
included in cost-effectiveness analyses        ment of  smoking cessation as the "gold              17. Rice DP, Hodgson TA, Sincheimer P, et al. The
has been debated in the literature.21"25       standard"   by which all other screening             economic costs of the health effects of smoking, 1984.
Warner and Luce22 argue that offsetting        tests can be compared. Of course, the                Milbank Q. 1986;64:489-547.
                                                                                                    18. National Center for Health Statistics. Current
the lower medical costs ofnonsmokers in        guideline does not address public health             Estimates From the National Health Interview
their working lifetimes by higher medi¬        strategies aimed at stopping smoking that            Survey, 1992. Hyattsville, Md: US Public Health
cal costs because of their longer lives ig¬    may be even more cost-effective relative             Service; 1993. Publication PHS 93-1509.
nores the consumption (and productiv¬          to clinical smoking cessation treatments.            19. American Hospital Association. Hospital Sta-
                                                  In summary, our findings reinforce                tistics. 1994-1995 ed. Chicago, Ill: AHA Services Inc;
ity) gains from living longer.                                                                      1994.
    In any event, recent analysis25 has        the guideline's central challenge to cli¬            20. US  Dept of Health and Human Services. Re-
shown that net medical costs over a per¬       nicians, insurers, purchasers, and ad¬               ducing the Health Consequences of Smoking: 25
son's lifetime are $6239 higher for US         ministrators to identify and intervene               Years ofProgress: A Report ofthe Surgeon General.
smokers (in discounted 1990 dollars),          universally with all smokers presenting              Washington, DC: US Dept of Health and Human
                                               in a health care setting.                            Services; 1989. DHHS publication 89-8411.
during his or her remaining lifetime than                                                            21. Weinstein MC, Stason WB. Foundation of cost\x=req-\
people who never smoked. Simply count¬           This article was prepared under contract No.
                                                                                                     effectiveness analysis for health and medical prac-
ing the excess medical costs of smokers        282-95-2002 from the Agency for Health Care Policy
                                                                                                     tices. N Engl J Med. 1977;296:716-721.
to age 65 years averages $9000 to                                                                    22. Warner K, Luce B. Cost-Benefit and Cost-effec-
                                               and Research, US Department of Health and Hu¬         tiveness Analysis in Health Care: Principals, Prac-
$11000.26 Subtracting excess medical           man Services; Kathleen A. Weis, DrPH, NP, was
                                                                                                     tice, and Potential. Ann Arbor, Mich: Health Ad-
costs from the guideline's average cost        the project officer.                                  ministration Press; 1982.
per life-year saved would turn the ratio       References
                                                                                                     23. Russell L. Is Prevention Better Than Cure?
negative, implying that smoking cessa¬                                                               Washington, DC: Brookings Institution; 1986.
tion interventions actually save more in       1. Centers for Disease Control and Prevention.        24. Drummond MR, Stoddart GL, Torrance GW.
                                               Cigarette smoking\p=m-\attributablemortality and      Methods for the Economic Evaluation of Health
lifetime medical expenditures than they                                                              Care Programmes. Oxford, England: Oxford Uni-
                                               years of potential life lost: United States, 1990.
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lifetime medical expenditures from our         2. Fiore MC, Bailey WC, Cohen SC, et al. Smoking      25. Gold MR, Siegel JE, Russel LB, Weinstein MC.
analysis, we believe the guideline could       Cessation: Clinical Practice Guideline No. 18.        Cost-effectiveness in Health and Medicine. New
be considered even more cost-effective         Rockville, Md: Agency for Health Care Policy and      York, NY: Oxford University Press; 1996.
                                               Research; April 1996. Publication No. 96-0692.        26. Hodgson TA. Cigarette smoking and lifetime
than reported above.                           3. Centers for Disease Control and Prevention.        medical expenditures. Milbank Q. 1992;70:81-125.
    Moreover, our analysis does not at¬        Physician and other health care professional coun-    27. Tengs T, Adams M, Pliskin J, et al. Five-Hun-
                                               seling of smokers to quit: United States, 1991.       dred Life-Saving Interventions and Their Cost-ef-
tempt to compare the psychosocial costs        MMWR Morb Mortal Wkly Rep. 1993;43:925-930.          fectiveness. Cambridge, Mass: Harvard Center for
of smoking treatment, such as the pain         4. Robinson MD, Laurent SL, Little JM Jr. Includ-     Risk Analysis; 1995.
and suffering of nicotine withdrawal, with     ing smoking status as a new vital sign: it works.     28. Eddy DM. David Eddy ranks the tests. Har-
the pain and suffering produced by other       J Fam Pract. 1995;40:556-563.                         vard Health Letter. July 1992:10-11.


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