Understanding the Financial Consequences of Smoking During Cancer Treatment in the Era of Value-Based Medicine

Warren et al¹ provide a model for identifying the overall costs of first-line cancer treatment failure attributable to continued smoking among patients with cancer. The results show that the increase in first-line cancer treatment failure attributed to smoking was associated with significant incremental costs for subsequent cancer treatments and that this may justify development of strategies to mitigate those costs.

The model provides a conceptual representation of the economic effects of smoking-attributed first-line cancer treatment failure. To account for the known complexity and variation in cancer treatment outcomes, Warren et al¹ modeled a wide range of values for smoking prevalence, expected cure rates across different treatment and diagnostic conditions, risks from continued smoking, and cost of subsequent care. The authors developed ranges for the clinical input values based on the results of multiple empirical studies that examined smoking prevalence among patients with cancer and the association of continued smoking with cancer treatment outcomes across different disease sites and treatment models. To simplify the analysis, costs were represented using a defined incremental cost per treatment after first-line cancer treatment failure. The model was empirically inspired, but more research is needed to better estimate the specific measures that affect costs. With various assumptions for differences in treatment type and cost structures within an institution or region, the cost estimates for first-line cancer treatment failure attributed to smoking ranged from $10 000 to $250 000.

The type of analysis modeled is particularly relevant in today's health care system, which is increasingly focused on delivering value-based care that accounts for both clinical effectiveness and cost of treatment. This study provides a tool for representing the economic consequences of a known clinical phenomenon to show that continued smoking during cancer treatment not only harms patient health^2-4 but also creates a financial burden for patients, clinicians, and the health care system overall. Although there are resources available for educating clinicians about best practices for smoking cessation among patients with cancer, such as the National Comprehensive Cancer Network guidelines, these resources are limited to informing direct clinical practice and do not provide a means for estimating the association of smoking with cost or treatment outcomes.⁵ Our health care system tolerates a misalignment of clinical and financial realities. The effects of continued smoking during cancer treatment have been well-documented,^2-4 but resources for smoking cessation services remain inadequate. Coverage for smoking cessation by insurance companies is limited and tends to disproportionately favor medical interventions, such as smoking cessation medications, compared with evidence-based behavioral interventions.⁶ Smoking cessation results, as with many preventive public health measures, are invisible when they work to keep people from getting sick. Smoking cessation does not generate much revenue, involves complex behavioral change, and disproportionally affects marginalized populations. Thus, smoking cessation fails to attract the attention of systems and clinicians who, although concerned with the health of their patients, operate within the constraints of an increasingly tight financial environment.

To show the clinical association of smoking with first-line cancer treatment failure in financial terms places continued smoking during cancer treatment alongside surgery and chemotherapy as a significant contributor to cancer treatment costs. By adjusting the inputs to reflect unique population characteristics and treatment outcomes, health care systems and clinicians could use this model to identify the specific economic consequences of continued smoking and use this information in conjunction with clinical data to determine the best strategy for incorporating evidence-based interventions to maximize clinical outcomes while minimizing costs. This model indicates that providing the resources and infrastructure to help every patient with cancer to stop smoking should yield better outcomes while saving costs. Smoking cessation interventions are clinically effective and cost-effective⁷ and should be part of the treatment plan for every patient with cancer alongside decisions about which surgical procedure, chemotherapy, or radiotherapy is appropriate.

The model also provides a foundation on which future research can begin to delve into specific measures influencing the clinical and financial outcomes associated with continued smoking in patients with cancer. The analysis performed was limited by the choice to represent smoking prevalence as a static percentage of the population. Smoking cessation, however, is a temporal phenomenon, which adds nuance to its effectiveness that future studies should examine. For example, when is the best time for smoking cessation—before, during, and/or after treatment? For what duration? Is abstinence from smoking required, or are smoking reductions sufficient? Is the mechanism of action through nicotine itself or cigarette smoking? How does the use of other nicotine-containing products, such as nicotine patches or electronic cigarettes, affect outcomes and costs? These and other important questions should be addressed and linked with clinical outcomes and costs to improve our understanding of model inputs and mechanisms driving these phenomena. The results suggest an indirect benefit to reducing smoking prevalence urgently among patients with cancer. Results of the study by Warren et al¹ support increasing resources for smoking cessation services. Medical professionals may take an interest both in helping every patient with cancer to stop smoking and in supporting population-based smoking prevention strategies, such as public education campaigns, smoke-free policies, and price increases for tobacco products.

The future of health care is focused on value-based medicine and providing the best care at the lowest cost. It will become increasingly important for clinicians and organizations to be able to accurately identify and analyze both the clinical and the financial consequences of health care and public health interventions. The study by Warren et al¹ provides a means for representing the economic effects of clinical phenomena—a valuable tool in a changing health care environment.

Published: April 5, 2019. doi:10.1001/jamanetworkopen.2019.1713

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2019 Petrucci CM et al. JAMA Network Open.

Corresponding Author: Cara M. Petrucci, MBA, MPH, Department of Health Behavior, Roswell Park Comprehensive Cancer Center, Elm and Carlton Streets, Carlton House 412, Buffalo, NY 14263 (cara.petrucci@roswellpark.org).

Conflict of Interest Disclosures: None reported.