Public investment in smoking cessation

Abstract

The economic evidence indicates that pharmacotherapy (PT)-based smoking cessation interventions are likely to offer good value from public healthcare investment. Even with low rates of long-term abstinence, PT therapy is among the most cost-effective cancer control interventions available. The arguments for providing universal access to PT are strong, however perhaps not as important as ensuring that PT and/or other smoking cessation interventions and services are used by people who need them. In 2018, nearly every Canadian has access to one 12-week course of PT per year; however, this is not enough to maximize the public health benefits that could be gained from smoking cessation interventions. The evidence show that program participation and long-term abstinence rates can be maximized by including behavior-based supports, individualized program invitations, and adapting programs to local or disadvantaged context. Long-term abstinence and participation rates are the greatest drivers of cost-effectiveness. Improving these outcomes, therefore, is the best way to maximize public investment in smoking cessation. Canadian policy needs to consider this evidence in the design and implementation of programs and to collect health information data on a national level to track success rates.

Keywords:

• Smoking cessation
• cost-effectiveness
• pharmacotherapy

This article refers to:

Cost-effectiveness of universally funding smoking cessation pharmacotherapy

In this issue Altman et al. use cost-effectiveness analysis to show that formulary adoption of pharmacotherapy (PT)-based smoking cessation interventions is likely to be considered good value for the healthcare dollar. Their results agree with other studies that estimate incremental cost-effectiveness ratios to be lower than $10,000 per quality adjusted life year gained, over placebo or passively delivered services.^1,2 Together, the economic evidence make a convincing case for universal coverage of PT, especially when compared with the cost-effectiveness of treatments for tobacco-related illness. For example, the last three drugs entering the Canadian market to treat non-small cell lung cancer cost over $200,000 per quality adjusted life year gained. The focus on universal funding is important; however, further improvement to the way programs are delivered will maximize payback from public investment in smoking cessation. The main drivers of cost-effectiveness in the economic models are participation rates in smoking cessation programs (less than 16% of all eligible) and the long-term abstinence rates—lower than 20%, in PT trials.³

As of April 2018, every province and territory in Canada provides at least some coverage for one 12-week course of PT per year, with varying degrees of co-payment.⁴ The national policy is however, not entirely universal; some co-payments require substantial investment from patients and/or have gaps in coverage. For example, patients in Manitoba could be required to make co-payments of up to $350 for treatment if they are not registered to receive income assistance. Another area of concern is that usually PT is only covered for one quit attempt per year, which is contrary to what is known about the number of quit attempts required to achieve long-term abstinence.⁵ The evidence suggests that there are also policy gaps in provision of behavioral supports. For example, the pivotal trial showing efficacy for varenecline, one of the most commonly reimbursed PT, was generated from participants who also received weekly, face-to-face smoking cessation counseling.⁵ Ontario is the only province that pro-actively combines behavioral supports with prescriptions of PT, while some other jurisdictions do provide free telephone coaching. The success of smoking cessation can be improved by up to 60% when PT is combined with behavior-based support, and simple support services are not costly.^2,6

The most compelling economic arguments are therefore related to participation and abstinence rates, calling for policy on program delivery in Canada. Implementation strategies need to overcome barriers that are preventing people from using and following through with smoking cessation. Such approaches involve adapting programs to meet local and/or disadvantaged contexts. Using personal risk reporting, for example, has improved both participation and long-term abstinence rates for the English Stop Smoking program.⁷ Some health care trusts in England have also adopted their programs to serve small and deprived communities by mobilizing smoking cessation practitioners through the country’s “Lung Health Check” program. The mobile clinics operate inside imaging vans, which are stationed in the parking lots of local supermarkets. People who are found to have a high risk of developing lung cancer are also provided with radiographic images of their heart and lungs.⁸ Success is monitored with data from routine expired carbon monoxide readings that also enables the program to make improvements and track long-term participation and abstinence rates.