Cost-effectiveness analysis of face-to-face smoking cessation interventions by professionals

Objectives: To estimate the cost-effectiveness of five face-to-face smoking cessation interventions: 1) Telephone Counseling (TC), 2) Minimal counseling by a general practitioner (H-MIS), 3) Minimal counseling by a general practitioner combined with Nicotine Replacement Therapy (H-MIS+NRT), 4) Intensive Counseling combined with Nicotine Replacement Therapy (IC+NRT) and 5) Intensive Counseling combined with Bupropion (IC+Bupr), in terms of costs per quitter, costs per life-year gained and costs per quality-adjusted life-year (QALY) gained. Methods: Scenarios on increased implementation of smoking cessation interventions were compared to current practice. Base-case scenarios assumed that one of the five interventions was implemented for a period of either 1 year, 10 years or 75 years and reached 25% of the smokers. A computer simulation model, the RIVM Chronic Disease Model, was used to project future gains in life-years and Quality Adjusted Life Years (QALYs), and savings of health care costs from a decrease in the incidence of smoking-related diseases. Regardless of the duration for which the intervention was implemented, our time horizon was 75 years, i.e. costs and effects were studied over a period of 75 years. Intervention costs were computed based on bottom up estimates of resource use and costs per unit of resource use. Cost calculations of smoking cessation interventions were carried out from a health care perspective, i.e. total direct medical costs were calculated based on estimates of real resource use. Effectiveness in terms of cessation rates was obtained from Cochrane meta-analyses. For the base-case scenarios, future costs and effects were discounted at an annual percentage of 4%. Incremental cost-effectiveness ratios were calculated as: (additional intervention costs minus the savings from a reduced incidence of smoking related diseases) / (gain in health outcomes). A series of one-way sensitivity analyses were performed to assess the robustness of the cost-effectiveness ratios with regard to variations in cessation rates, intervention costs, discount rates, time horizon, and the percentage of smokers reached by the intervention. Results: Base-case estimates for costs per quitter ranged from Euro 443 for H-MIS to Euro 2800 for IC+NRT. Compared to current practice H-MIS is a dominant intervention regardless of the duration of implementation. This means that H-MIS not only generates gains in life years and QALYs but its saving are higher than its intervention costs. The four other interventions had relatively low cost-effectiveness ratios when compared to many other preventive interventions. When implementing each of the interventions for a period of 75 years, their ratios varied from about Euro 1400 per life year gained for TC to Euro 6200 per life year gained for IC+NRT. Incremental costs per QALY gained were Euro 1100 for TC, Euro 1400 for H-MIS+NRT, Euro 3400 for IC+Bupr, and Euro 4,900 for IC+NRT. Results were most sensitive to the rate of discounting. Conclusions: All five smoking-cessation interventions are very cost-effective, with ratios far below Euro 20000. H-MIS is even cost saving.