1. 1 Cost efficacy of smoking cessation interventions Robert West University College London Logroño, October 2006 www.rjwest.co.uk

2. 2 Outline Health benefits of cessation Effectiveness of cessation interventions Cost-effectiveness calculation

3. 3 Benefits of smoking cessation: life-expectancy Stopping smoking permanently increases life expectancy by: –9 years if stopped around age 40 years –6 years if stopped around age 50 years –3 years if stopped around age 60 years For every year that smoking cessation is brought forward, life-expectancy increases by 3 months Doll R et al. BMJ. 2004;328:1519–1527

4. 4 Benefits of smoking cessation: morbidity Smokers spend more of their lives with pain, ill health and disability from: –Chronic Obstructive Lung Disease –Coronary Heart Disease –Peripheral vascular disease –Blindness –Deafness –Dementia –Stroke –Osteoporosis West, R (2006) British Medical Bulletin, in press

5. 5 Benefits of smoking cessation: smoking in pregnancy Stopping smoking before or early in pregnancy reduces risk of: –Infertility –Spontaneous abortion –Stillbirth –Low birth weight (with later risk of COPD and heart disease) –Conduct disorder and criminality in the offspring –Sudden infant death syndrome in the offspring West, R (2006) British Medical Bulletin, in press

6. 6 Benefits of smoking cessation: secondary prevention Smoking cessation: –normalises the rate of decline in lung function in patients with COPD, and reduces the rate of exacerbations and mortality from respiratory and cardiovascular diseases –improves prognosis in patients with lung cancer Anthonisen N, et al Ann Int Med 2005; 142, 233-239 Kawahara M, et al Br J Cancer 1998;78:409-12.

7. 7 Effectiveness of smoking cessation interventions Percentage of smokers who achieve 6 months of continuous abstinence who would not have done so otherwise: –Face-to-face individual counselling 2-8% –Pro-active telephone counselling 2-4% –Group counselling/support 3-9% –NRT 5-8% –Bupropion 7-13% –Varenicline 14-22% These estimates and those in the following graphs are approximate, based on a simple analysis assuming no heterogeneity across studies

8. 8 Effect of face-to-face individual support Using only studies with ≥6 months’ continuous abstinence and biochemical verification

9. 9 Effect of group support Using only studies with ≥12 months’ continuous abstinence and biochemical verification

10. 10 Effect of telephone counselling Cochrane review: >6 month cessation not validated

11. 11 Effect of tailored internet support Not biochemically verified

12. 12 Effect of NRT Cochrane: LI: Low intensity behavioural support; HI: High intensity behavioural support RTS: Reduce To Stop; Combination: various combinations versus single NRT types; Population: NRT versus no NRT in population samples without behavioural support (ATTEMPT – cohort study, not RCT)

13. 13 Effect of nortriptyline, bupropion and varenicline For bupropion and nortriptyline data from Cochrane: ≥6 months’ continuous abstinence and biochemical verification; varenicline 6 month continuous abstinence data from JAMA 2006; blue shading shows effect on 12 month continuous abstinence rates of further 12w varenicline vs placebo in smokers abstinence at 12w

14. 14 Cost effectiveness calculations Approximately 50% of those who abstain for 6 months achieve long- term cessation (8 years or more) Thus smoking cessation interventions typically achieve an increase of 1% to 7% permanent cessation on worst case estimates Without treatment, the average age of quitting of a 40 year-old smoker is ~ 65 years Therefore a 40 year-old smoker who is help to stop will gain an average 6 years of life (9 years minus 3 years) Treating 100 40 year-old smokers will yield a minimum of 6 to 42 years of life years If a treatment episode costs an average 150 euros, this represents a cost per life year gained of 360 to 2500 euros undiscounted (~720 to 5000 euros discounted at 3% for 20 years) The UK National Institute of Clinical Excellence has an informal benchmark of 30,000 euros per quality-adjusted life year gained as threshold for value for money for the National Health Service

15. 15 Conclusions Current treatments to aid smoking cessation are highly cost-effective for reducing premature death This does not take account of prevention of pain and disability Even the least effective methods represent excellent value for money These clinical interventions are not a substitute for government action on price, smoke-free workplaces and media campaigns which will reduce overall smoking prevalence