Health economics
economic assessments of
interventions to promote smoking
cessation
Last updated January 2014

Heath Economics section
Chair
Hana Ross
Managing Director
Research, American Cancer Society, USA
Frank Chaloupka
Distinguished Professor
Dept. of Economics University of Illinois, USA
Christine Godfrey
Professor of Health Economics
University of York, UK
Ken Warner
Distinguished Professor
University of Michigan, USA
Trevor Woollery
Economist
Centers for Disease Control and Prevention,
USA
Ayda Yurekli
Senior Economic Advisor
World Health Organization, Tobacco Free
Initiative, Switzerland
Last updated January 2014
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Purpose
• To provide information on economic assessments of
interventions to promote smoking cessation.
Last updated January 2014
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Evidence Base
• Based on evidence presented largely in the other
databases.
• Strength of evidence statements therefore not given.
Last updated January 2014
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Key Findings
Impacts of Cessation
• Smoking cessation reduces individual smokers’ risk
of morbidity and mortality in the short and long terms
• Smoking cessation is important for long-term
improvements in workplace productivity, health care
costs, and the public health
Jha P, Ramasundarahettige C, Landsman V, Rostron B, Thun M, Anderson RN, McAfee T, Peto R. 21st-Century hazards of smoking and benefits of
cessation in the United States. N Engl J Med 2013;368:341-350.
Méndez D, Alshanqeety O, Warner KE. The potential impact of smoking control policies on future global smoking trends. Tobacco Control 2013;22(1):
46–51.
Eriksen M, MacKay J, Ross H. The Tobacco Atlas, 4th ed. American Cancer Society, 2012.
Halpern MT, Dirani R, Schmier JK. Impacts of a Smoking Cessation Benefit Among Employed Populations. J Occup Environ Med. 2007; 49(1): 11-21.
Last updated January 2014
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Key Findings
Cost-Effectiveness
• Public health policies that promote smoking cessation
are highly cost-effective.
• Tobacco excise tax increases
• Public and workplace smoking bans
• Anti-smoking media campaigns
• Quitlines
• Pharmacotherapy, including nicotine replacement therapy and
prescription drugs
Ranson MK, Jha P, Chaloupka FJ, Nguyen SN. The effectiveness and cost-effectiveness of price increases and other tobacco control policies. In Jha P,
Chaloupka FJ, eds. Tobacco control in developing countries, 2000; pp.427-447 (Section V, Chapter 18).
Ross H, Blecher E, Yan L, Hyland A. Do cigarette prices motivate smokers to quit? New evidence from the ITC survey. Addiction. 2011; 106(3): 609-619.
Fichtenberg CM. Glantz SA. Effect of smoke-free workplaces on smoking behavior: systematic review. BMJ. 2002; 325: 188-191.
Cornuz J, Gilbert A, Pinget C, McDonald P, Slama K, Salto E, Paccaud F. Cost-effectiveness of pharmacotherapies for nicotine dependence in primary
care settings: a multinational comparison. Tob Control, 2006; 15(3): 152-159.
Last updated January 2014
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Key Findings
Cigarette Prices
• In general, tobacco excise tax increases raise cigarette prices
• Among adults, higher cigarette prices reduce cigarette consumption by,
• Inducing smoking cessation
• Helping those who quit stay quit
• Decreasing the number of cigarettes smoked by continuing users
• Among young people, higher cigarette prices reduce initiation of regular
smoking
• Smoking in lower socioeconomic groups is more responsive to
cigarette price increases than in higher economic groups
Ross H, Kostova D, Stoklosa M, Leon M. The impact of cigarette excise taxes on smoking cessation rates from 1994 to 2010 in Poland, Russia, and
Ukraine. Nicotine Tob Res. 2014; 16(S1): S37-43.
Zhang B, Cohen J, Ferrence R, Rehm J. The impact of tobacco tax cuts on smoking initiation among Canadian young adults. Am J Prev Med. 2006;
30(6): 474-479.
Blecher E, van Walbeek C. An Analysis of Cigarette Affordability. Paris: International Union Against Tuberculosis and Lung Disease; 2008.
Last updated January 2014
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Key Findings
Nicotine Replacement Therapy (NRT)
• In clinical trials, use of NRT increases quit rates in the
short term as well as promotes long term abstinence
• Demand for NRT is…
• inversely related to the demand for cigarettes
• directly related to health insurance coverage
• Inversely related to out-of-pocket cost
• NRT consumption has decreased the demand for
cigarettes
• Patch and gum are among WHO’s Essential Medicines
Stead LF, Perera R, Bullen C, Mant D, Hartmann-Boyce J, Cahill K, Lancaster T. Nicotine replacement therapy for smoking cessation. Cochrane
Database of Systematic Reviews 2012, Issue 11. Art. No.: CD000146.pub4.
Tauras JA, Chaloupka FJ. The demand for nicotine replacement therapies. Nicotine Tob Res. 2003; 5(2): 237-243.
Solberg LI. Impact of insurance coverage on the use and effects of smoking cessation medications. Dis Manage Health Outcomes. 2005; 3(13): 151-158.
World Health Organisation. Two forms of nicotine replacement therapy chosen as WHO "Essential Medicines". 17th Expert Committee on the Selection
and Use of Essential Medicines. 2009.
Last updated January 2014
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Key Findings
Comprehensive Cessation Interventions
• Community-based programs that use nurses and
pharmacists are cost-effective in reducing tobacco use
• Even brief advice by a physician increases the
probability of a smoker quitting
• Adequate, sustained funding for comprehensive tobacco
control programs is effective at reducing smoking
Rice VH, Hartmann-Boyce J, Stead LF. Nursing interventions for smoking cessation. Cochrane Database Syst Rev. 2013; 8: CD001188.pub4.
Stead LF, Buitrago D, Preciado N, Sanchez G, Hartmann-Boyce J, Lancaster T. Physician advice for smoking cessation. Cochrane Database of
Systematic Reviews 2013, Issue 5. Art. No.: CD000165.pub4.
Farrelly MC, Pechacek TF, Thomas KY, Nelson D. The impact of tobacco control programs on adult smoking. Am J Public Health. 2008; 98(2): 304-309.
Last updated January 2014
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Key Findings
Health Insurance and the Workplace
• Providing workplace smoking cessation coverage leads
to health and economic benefits for both employers and
insurers
• Workplace smoking bans reduce both smoking
prevalence and smoking intensity
• Workplace-based cessation programs constitute a costeffective investment for employers
Ross H. Economics of smoke free policies. In Lifting the smokescreen: 10 reasons for going smokefree. Smoke Free Partnership, March 2006.
Fichtenberg CM. Glantz SA. Effect of smoke-free workplaces on smoking behavior: systematic review. BMJ. 2002; 325: 188-191.
IARC. Evaluating the Effectiveness of Smoke-free Policies, IARC Handbook of Cancer Prevention, Volume 13, International Agency for Research on
Cancer, World Health Organization, 2009.
Last updated January 2014
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Key Findings
Quitlines
• Quitlines effectively promote cessation across a wide
variety of populations
• Television, radio, web, and print media tobacco control
advertising all increase calls to smokers’ quitlines
• Multiple callbacks from quitlines increase long-term
cessation rates
• Offering free NRT through a quitline increases quitline
utilization and quit rates
Stead LF, Hartmann-Boyce J, Perera R, Lancaster T. Telephone counselling for smoking cessation. Cochrane Database Syst Rev. 2013 Aug
12;8:CD002850.pub3.
Free C, Knight R, Robertson S, Whittaker R, Edwards P, Zhou W, Rodgers A, Cairns J, Kenward MG, Roberts I. Smoking cessation support delivered via
mobile phone text messaging (txt2stop): a single-blind, randomised trial. Lancet. 2011; 378: 49–55.
McAfee T, Davis KC, Alexander RL Jr, Pechacek TF, Bunnell R. Effect of the first federally funded US antismoking national media campaign. Lancet.
2013: S0140-6736(13)61686-4.
Cummings KM, Fix B, Celestino P, Carlin-Menter S, O'Connor R, Hyland A. Reach, efficacy, and cost-effectiveness of free nicotine medication giveaway
programs. J Public Health Manag Pract. 2006; 12(1): 37-43.
Last updated January 2014
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Key Findings
Vulnerable Populations
•
Cessation programs for patients with smoking-related health problems are
very cost effective
•
Reductions in smoking can reduce health disparities between the rich and
the poor
•
Targeted programs encouraging smoking cessation in pregnant women are
highly cost-effective
•
Living in an economically deprived area can increase the difficulty of quitting
smoking
•
Individual smokers suffer economic hardship as a result of smoking
Rigotti NA, Clair C, Munafò MR, Stead LF. Interventions for smoking cessation in hospitalised patients. Cochrane Database Syst Rev.
2012;5:CD001837.pub3.
Siahpush M, Wakefield MA, Spittal MJ, Durkin SJ, Scollo MM. Taxation reduces social disparities in adult smoking prevalence. Am J Prev Med. 2009; 36(4):
285-291.
Hosseinpoor AR, Parker LA, Tursan d'Espaignet E, Chatterji S. Socioeconomic inequality in smoking in low-income and middle-income countries: results from
the World Health Survey. PLoS One. 2012;7(8):e42843.
Chamberlain C, O'Mara-Eves A, Oliver S, Caird JR, Perlen SM, Eades SJ, Thomas J. Psychosocial interventions for supporting women to stop smoking in
pregnancy. Cochrane Database Syst Rev. 2013; 10: CD001055.pub4.
Christiansen B, Reeder K, Hill M, Baker TB, Fiore MC. Barriers to effective tobacco-dependence treatment for the very poor. J Stud Alcohol Drugs. 2012;
73(6): 874-84.
John RM, Ross H, Blecher E. Tobacco expenditures and its implications for household resource allocation in Cambodia. Tob Control. 2012 May;21(3):341-6.
Last updated January 2014
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Recommendations
• Effective population-based and low-cost individual-level
interventions should be used to aid cessation
• Comprehensive evidence-based cessation interventions
should be covered under all health insurance plans
• Smoking cessation services should be available to
population groups with high tobacco use prevalence
– e.g. low income, less educated, those with a mental
illness
– Interventions must be tailored to reach high-risk
populations.
Last updated January 2014
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Recommendations (cont.)
• NRT should be available and affordable for general sale,
as it is a viable and cost-effective cessation aid
• Evaluate the impact of strategies used by smokers to
reduce their out-of-pocket expenses on their motivation
to quit and their quit success rate
• Create simple briefs outlining the social and economic
benefits of smoking cessation to be disseminated among
decision-makers
Last updated January 2014
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Areas for future research
• Assess economic aspects of smoking cessation
interventions globally, especially in low- and middleincome countries
• Determine what can motivate smokers to try to quit more
often
• Study the impact of tobacco excise tax structure and the
resultant degree of product price variation on motivation
for cessation and successful quitting
• Assess price and income elasticities of demand for
cessation services in developed and developing
countries
Last updated January 2014
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Areas for future research (cont.)
• Examine the relationship between higher nicotine
dependence and price sensitivity or successful cessation
• Study peer and family effects on the demand for smoking
cessation among young smokers
• Study effects of e-cigarette uptake on smoking cessation
• Study whether charging higher health insurance
premiums is a sufficient motivator for smoking cessation
• Examine the nature of the relationship between physical
exercise and smoking cessation
Last updated January 2014
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