December 3, 1997

Cost-effectiveness of the Clinical Practice Recommendations in the AHCPR Guideline for Smoking Cessation

Author Affiliations

From Health Economics Research, Inc, Waltham, Mass (Dr Cromwell and Mr Bartosch); the Center for Tobacco Research and Intervention (Drs Fiore and Baker), Section of General Internal Medicine, Department of Medicine (Drs Fiore and Baker), Comprehensive Cancer Center (Dr Fiore), and Department of Psychology (Dr Baker), University of Wisconsin Medical School, Madison; and the Center for Health Policy Research and Education, Duke University, Durham, NC (Dr Hasselblad).

JAMA. 1997;278(21):1759-1766. doi:10.1001/jama.1997.03550210057039

Context.  —The Agency for Health Care Policy and Research (AHCPR) published the Smoking Cessation: Clinical Practice Guideline in 1996. Based on the results of meta-analyses and expert opinion, the guideline identifies efficacious interventions for primary care clinicians and smoking cessation specialty providers.

Objective.  —To determine the cost-effectiveness of clinical recommendations in AHCPR's guideline.

Design.  —The guideline's 15 recommended smoking cessation interventions were analyzed to determine their relative cost-effectiveness. Then, using decision probabilities, the interventions were combined into a global model of the guideline's overall cost-effectiveness.

Patients.  —The analysis assumes that primary care clinicians screen all presenting adults for smoking status and advise and motivate all smokers to quit during the course of a routine office visit or hospitalization. Smoking cessation interventions are provided to 75% of US smokers 18 years and older who are assumed to be willing to make a quit attempt during a year's time.

Intervention.  —Three counseling interventions for primary care clinicians and 2 counseling interventions for smoking cessation specialists were modeled with and without transdermal nicotine and nicotine gum.

Main Outcome Measure.  —Cost (1995 dollars) per life-year or quality-adjusted life-year (QALY) saved, at a discount of 3%.

Results.  —The guideline would cost $6.3 billion to implement in its first year. As a result, society could expect to gain 1.7 million new quitters at an average cost of $3779 per quitter, $2587 per life-year saved, and $1915 for every QALY saved. Costs per QALY saved ranged from $1108 to $4542, with more intensive interventions being more cost-effective. Group intensive cessation counseling exhibited the lowest cost per QALY saved, but only 5% of smokers appear willing to undertake this type of intervention.

Conclusions.  —Compared with other preventive interventions, smoking cessation is extremely cost-effective. The more intensive the intervention, the lower the cost per QALY saved, which suggests that greater spending on interventions yields more net benefit. While all these clinically delivered interventions seem a reasonable societal investment, those involving more intensive counseling and the nicotine patch as adjuvant therapy are particularly meritorious.