Economics of smoking cessation

Introduction

Smoking imposes a huge economic burden on society—currently up to 15% of total healthcare costs in developed countries. Smoking cessation can save years of life, at a very low cost compared with alternative interventions. This chapter reviews some of the economic aspects of smoking cessation.

Self rated health status (100 = best imaginable health state), by age and smoking status. Data from Kind et al.UK population norms for EQ-5D. York: Centre for Health Economics (Discussion paper 172)

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Who benefits from cessation?

The most obvious benefits of smoking cessation are improvements in life expectancy and prevention of disease. However, cessation also improves individuals' quality of life as smokers tend to have a lower self reported health status than non-smokers, and this improves after stopping smoking.

There are also wider economic benefits to individuals and society, arising from reductions in the effects of passive smoking in non-smokers and savings to the health service and the employer. These wider benefits are often omitted from economic evaluations of cessation interventions, which consequently tend to underestimate the true value for money afforded by such programmes.

Economic burden of smoking

Many estimates have been made of the economic cost of smoking in terms of health resources. For the United States they typically range from about 0.6% to 0.85% of gross domestic product. In absolute terms, the US public health service estimates a total cost of $50bn (£29bn;€42bn) a year for the treatment of smoking related diseases, in addition to an annual $47bn in lost earnings and productivity. Estimated total costs in Australia and Canada, as a proportion of their gross domestic product, are 0.4% and 0.56% respectively. In the United Kingdom, the treatment of smoking related disease has been estimated to cost the NHS £1.4bn-£1.5bn a year (about 0.16% of the gross domestic product)—including £127m to treat lung cancer alone.

When expressed as a percentage of gross domestic product, the economic burden of smoking seems to be rising. In reality, however, the burden may not be increasing, but instead, as more diseases are known to be attributable to smoking, the burden attributed to smoking increases. Earlier estimates may simply have underestimated the true cost.

Passive smoking

In the United States, passive smoking has been estimated to be responsible for 19% of total expenditure on childhood respiratory conditions, and maternal smoking has been shown to increase healthcare expenditure by $120 a year for children under age 5 years and $175 for children under age 2 years.

In Puerto Rico, China (above), and Venezuela, the cost of smoking has been estimated as 0.3%-0.43% of the gross domestic product

In the United Kingdom an estimated £410m a year is spent treating childhood illness related to passive smoking; in adults, passive smoking accounts for at least 1000 deaths in non-smokers, at an estimated cost of about £12.8m a year at 2002 prices.

Cost of absenteeism

Absenteeism arising from smoking related disease is also a major cause of lost productivity, a cost incurred by employers. An annual estimated 34 million days are lost in England and Wales through sickness absence resulting from smoking related illness, and in Scotland the cost of this productivity loss is about £400m.

Cost effectiveness of cessation programmes

Clear evidence exists that smoking cessation interventions are effective. However, to show value for money, the costs as well as the effectiveness of such programmes have to be examined. The overwhelming evidence is that face to face cessation interventions provide excellent value for money compared with the great majority of other medical interventions.

Several complex factors influence cost effectiveness. For example, although a cessation programme tends to be more effective as its intensity increases, increased intensity is associated with increased costs, therefore increasing both sides of the cost effectiveness ratio. This was illustrated in a study by Parrott et al (1998) of the range of intensities of smoking cessation interventions in the United Kingdom. The researchers examined these interventions using local cost data and life years saved as predicted from the PREVENT simulation model. They looked at four interventions: a basic intervention of three minutes of opportunistic brief advice; brief advice plus self help material; brief advice plus self help material and nicotine replacement products; and brief advice plus self help material, nicotine replacement products, and a recommendation to attend a smoking cessation clinic. The most cost effective intervention was the brief advice alone (cost £159 per life year saved, £248 when discounted at 6%), although the most intensive clinical interventions still represent good value for money at £1002 per life year saved when discounted at 6%.

The cost effectiveness of putting the US Agency for Healthcare Research and Quality's clinical guidelines on smoking cessation into practice has also been estimated, for combined interventions based on smokers' preferences for different types of the five basic recommended interventions. The cost of implementation was estimated at $6.3bn in the first year, as a result of which society would gain 1.7 million new quitters at an average cost of $3779 per quitter, $2587 per life year saved, and $1915 per quality adjusted life year (QALY). In this study the most intensive interventions were calculated to be more cost effective than the briefer therapies.

Care should be taken when extrapolating the results of these evaluations, as cost effectiveness estimates are likely to be time and country specific and highly dependent on the healthcare system in question. In a system of fee for service, as in the United States, monetary rewards may be necessary to encourage provision. On the other hand, if patients who stop smoking place a reduced burden on the primary care budget in future years, the incentives to provide such services may be inherent in the system.

Cost effectiveness of smoking cessation interventions compared with that of routine strategies for preventing myocardial infarction

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