Published Online: October 14, 2011
Irena Pesis-Katz, PhD; Geoffrey C. Williams, MD, PhD; Christopher P. Niemiec, PhD; and Kevin Fiscella, MD, MPH
Objectives: To evaluate cost-effectiveness of a tobacco dependence intervention based on self-determination theory (SDT) and consistent with the Public Health Service (PHS)-sponsored Clinical Practice Guideline for Treating Tobacco Use and Dependence.
Study Design: Adult smokers were recruite into a randomized cessation-induction trial of an intensive intervention versus community care. Seven-day point prevalence (7dPP) tobacco abstinence and cost-effectiveness of the intervention were examined using 737 participants with health insurance.
Methods: Community care (CC) participants received smoking-cessation pamphlets and information on local treatment programs. Intervention participants received those materials and were asked to meet 4 times over 6 months with study counselors to discuss their health in a manner that supported autonomy and perceived competence. The third-party payer’s perspective was used for this analysis, and the primary outcome was cost-effectiveness using self-reported 7dPP tobacco abstinence at 6 months. Sensitivity analyses were performed using costs of generic medications, biochemically validated tobacco abstinence, actual rates of tobacco abstinence, life-years saved (not adjusted for quality of life), and costs in 2011 US dollars. A subgroup analysis was conducted using smokers who did not want to stop within 30 days.
Results: Smokers in the intervention, relative to CC, were more likely to attain 7dPP tobacco abstinence at 6 months. The overall incremental costeffectiveness ratio was $1258 per quality-adjusted life-year saved, in US dollars. The sensitivity and subgroup analyses yielded similar results.
Conclusions: An intervention based on SDT and consistent with the PHS Guideline facilitated tobacco abstinence among insured smokers and was cost-effective compared with other tobacco dependence and medical interventions.
(Am J Manag Care. 2011;17(10):e393-e398)
This study evaluated cost-effectiveness of an intensive tobacco dependence intervention based on self-determination theory and consistent with the Public Health Service-sponsored Clinical Practice Guideline for Treating Tobacco Use and Dependence.
Findings suggested that the intervention was highly cost-effective (about $1300 per quality-adjusted life-year in US dollars) among insured smokers, both for those who did and did not want to stop smoking within 30 days.
Sensitivity analyses indicated little variation in cost-effectiveness using generic medications, biochemically validated tobacco abstinence, actual rates of tobacco abstinence for each gender and age group, life-years saved (not adjusted for quality of life), and costs in 2011 US dollars.
Tobacco dependence is the leading cause of death in the United States and carries an estimated cost of $183 billion in US dollars per year in direct medical care and lost productivity.1,2 Interventions for smokers who want to stop within 30 days are cost-effective, requiring less than $2500 per quality-adjusted life-year (QALY) saved.3-6 This estimate compares favorably with other medical services, such as screening for hypertension among men aged 45 to 54 years ($5200 per QALY). Tobacco dependence treatments can also help prevent costly chronic conditions, such as heart and pulmonary disease, cancer, and various infectious diseases.7 However, there are few data on the cost-effectiveness of interventions that target all smokers, including those who do not want to stop within 30 days.
The objective of this effectiveness (ie, real world) study was to evaluate the cost-effectiveness of an intensive tobacco dependence intervention that targeted all smokers, both those who did and did not want to stop smoking within 30 days. The intervention was based on self-determination theory (SDT) and consistent with the Public Health Service (PHS)-sponsored Clinical Practice Guideline for Treating Tobacco Use and Dependence.8-11 Previous findings from this trial have documented the effectiveness of the intervention, relative to community care (CC), in facilitating tobacco abstinence at 6, 18, and 30 months postrandomization.12-14 The current analysis presents data on the cost-effectiveness of the intervention and, in doing so, advances the extant literature in 2 ways. Specifically, it provides the first cost-effectiveness analysis of an intensive tobacco dependence intervention that was intended to support autonomy and perceived competence and which was thus consistent with the principles of biomedical ethics.15 Also, it provides the third-party payer’s perspective on the cost-effectiveness of an intensive intervention that targeted all smokers, not only those who wanted to stop within 30 days.
Participants, Study Design, and Conditions
Data for the current cost-effectiveness analysis were obtained from a randomized cessation-induction trial of an SDT-based intervention intended to support autonomy and perceived competence. Cessation-induction trials differ from aid-to-cessation studies in that they include smokers regardless of whether they want to stop and, because smokers are not assigned a specific stop date, study outcomes are reported based on time from randomization.
Participants were recruited from the greater Rochester, New York area between January 2000 and July 2002 using newspaper advertisements and signs in physicians’ offices, and were enrolled in the study for 18 months (until January 2004). Although participants were enrolled in the study for 18 months, the intensive intervention was provided only during the first 6 months of the study and accordingly, the current analysis presents the 6-month costs and outcomes. Eligibility criteria were designed to yield a fairly representative sample of smokers, and included having smoked at least 100 cigarettes in their lifetime and 5 or more cigarettes per day during the week prior to enrollment, being at least 18 years of age, having the ability to read and speak English, having no history of psychotic illness (anxiety and depression were allowed), having a minimal life expectancy of 18 months, and planning to live in the greater Rochester, New York area for at least 18 months. Notably, having an intention to stop smoking was not an inclusion criterion and, thus, the study sample represented a broad population of smokers that varied in their intention to stop. The original sample included 1006 adult smokers with different insurance coverage, including private insurance, public insurance, and no insurance. Those without insurance were excluded from this analysis because we were interested in cost-effectiveness from the third-party payer’s perspective and because utilization of smoking-cessation services varies by existence and extent of health insurance.16 The final sample included 737 participants with health insurance.
A detailed description of the study design, recruitment procedures, treatment approach, and primary outcome results has been presented elsewhere.12-14,17 All study participants signed an informed consent form at the time of enrollment, received parking passes, and were paid $30 after completing the 6-month questionnaire (honoraria were prorated if participants withdrew from the study before completing it). Randomization was stratified by whether participants met the National Cholesterol Education Program guideline for low-density lipoprotein cholesterol.18 Because previous analysis of these data indicated no effect of the dietary intervention on tobacco outcomes, the dietary and tobacco conditions were collapsed and the current analysis focused only on the tobacco intervention and outcomes.13 About 70% of the insured participants (n = 526) were randomized to a 6-month SDT-based intervention, whereas the rest (n = 211) were randomized to CC. This ratio for random assignment was used to minimize harm to the CC condition, as the intervention was expected to have a more pronounced effect on tobacco abstinence.11 All CC participants were offered intensive treatment after completing the study. This protocol was approved by the University of Rochester’s Research Subjects Review Board.
Participants in the CC condition received the You Can Quit Smoking and Clearing the Air: Quit Smoking Today smoking-cessation pamphlets, the results of their cholesterol tests, and a list of all local smoking-cessation resources, including the New York State Quit Line.19 They were also encouraged to enroll in a smoking-cessation program and to consult with their physician about their smoking and cholesterol.Thus, this study examined whether the intervention facilitated improvement in tobacco outcomes compared with typical care available in the community.
Participants in the intervention condition received the same materials and advice as those in CC, and were asked to meet 4 times over 6 months with study counselors to discuss their health. The initial visit lasted 50 minutes, and follow-up visits lasted 20 minutes each. The intervention involved taking a medical and smoking history, eliciting and acknowledging participants’ perspectives on their smoking and its health risks, and discussing how stopping might improve health. Counselors presented participants with their 10-year absolute risk for developing coronary artery disease and the expected risk-reduction if they stopped smoking completely, and asked how they felt about that information.20,21 Participants discussed life aspirations and were asked how smoking helped and/or hindered them in attaining those goals.22 Finally, participants were asked whether they wanted to stop using tobacco. If yes, counselors provided competence support, and those participants who wanted to use medication were given the option of obtaining it from their own healthcare provider or from a study prescriber. Available medications included all first-line smoking-cessation medications approved at the time of this trial (ie, nicotine replacement, bupropion SR). Those who were not ready to stop were asked to return in 2 months to discuss smoking cessation again. There was no limit on the number of contacts within the 6-month intervention period.
At 6 months postrandomization, participants responded either “yes” or “no” to having smoked a cigarette, even a puff, in the past 7 days and to having currently used a pipe, cigars, snuff, or chewing tobacco. To be classified as having attained 7-day point prevalence (7dPP) tobacco abstinence at 6 months, participants must have responded “no” to having used each form of tobacco listed above.
We adopted the thirdparty payer’s perspective for this analysis. All costs were estimated in 2003 US dollars (adjusted when appropriate) using the Consumer Price Index inflation tables provided by the US Department of Labor.23 Variable costs included the type and amount of personnel time (in-person and over-the-phone contact minutes with each participant), wages (including overhead), and self-reported purchase of recommended medications. The medication costs were based on contract pricing for brand-name and generic medications provided by the largest private insurer in the greater Rochester, New York area. Fixed costs were attributed across all participants and included program promotion, lab tests (lipid analysis), parking passes, computers (only applicable depreciation value), software, supplies, copying and printing, and postage. Rent, utilities, janitorial expenses, and taxes were included as fixed costs and attributed based on their relative use in the intervention. For those who received smoking-cessation consultation from their own physician, we included participants’ self-reported contact time in the cost estimates. Nonrecurring costs (eg,
program start-up, including staff training, development, research, and evaluation) were not included in the cost estimates. Table 1 provides all fixed and variable costs incurred per study participant.
Quality-Adjusted Life-Years Saved
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