Tobacco Use: Reducing Out-of-Pocket Costs for Evidence-Based Cessation Treatments

The CPSTF finding is based on evidence from a Community Guide systematic review published in 2001 (Hopkins, et al., search period 1980-May 2000) combined with more recent evidence (search period January 2000-July 2012). The systematic review was conducted on behalf of the CPSTF by a team of specialists in systematic review methods, and in research, practice, and policy related to reducing tobacco use and secondhand smoke exposure. This finding updates and replaces the 2000 Task Force finding on Reducing Client Out-of-Pocket Costs.

Eighteen studies were included in the review (5 from the previous review and 13 from the more recent search period). Included studies offered evidence-based treatments identified in Treating Tobacco Use and Dependence: 2008 Update (Fiore et al., 2008).

• Quit rates among tobacco users at follow-up periods of 3.5 months or longer: median absolute increase of 4.3 percentage points (interquartile interval [IQI]: 0.2 to 6.0 percentage points; 12 studies)
• Quit attempt rates: median absolute increase of 2.8 percentage points (IQI: -0.6 to 9.1 percentage points; 6 studies)
• Use of evidence-based cessation treatments among tobacco users attempting to quit: median absolute increase of 7.0 percentage points (IQI: 1.4 to 18.3 percentage points; 11 studies)
• Reductions in the prevalence of tobacco use were seen in two different populations (state employees and retirees in Wisconsin; Medicaid recipients in Massachusetts) after the provision of a new tobacco cessation benefit (2 studies).

Fifteen studies were included in the economic review. Estimates of cost-effectiveness were assessed in comparison to a conservative threshold of $50,000 per quality adjusted life year (QALY) saved. All monetary values from studies are reported in 2010 U.S. dollars.

• Cost-effectiveness estimates were provided in 5 studies.
  • Cost per QALY saved: median estimate $2,349/QALY (range of values: $1,290 to $24,647; 3 studies)
  • Cost per life year saved: $5,990 (1 study)
  • Cost per disability adjusted life year (a measure of life lost to death and disability) averted: $7,695 to $16,559 (1 study)
• Cost-benefit comparisons were included in 10 studies.
  • Eight out of 10 studies found that benefits of these interventions exceeded costs within 10 years. Estimate differences were attributable to the program provider (employer or insurer), type and duration of the cessation benefits implemented, and assumptions used to calculate savings.
  • One study evaluated the Medicaid population in Massachusetts and found net savings from reduced hospitalizations for cardiovascular conditions within 2 years, with a return of $3.12 for every $1 spent.

Overall, the economic evidence indicates that interventions to reduce out-of-pocket costs for evidence-based cessation treatments are cost-effective and may provide net savings to implementers.

Findings of this review should be applicable to the general population of tobacco users’ with health care coverage in the United States.

CPSTF identified several areas that have limited information. Additional research and evaluation could help answer the following questions and fill remaining gaps in the evidence base. (What are evidence gaps?)

Intervention Design

• Additional studies could explore thresholds for benefit use based on the amount of patient costs and co-pays.
• Does effectiveness differ by the ultimate provider of the cessation benefit change?
• Does provision of first dollar healthcare coverage for evidence-based cessation treatments affect patient use, provider use, and effectiveness?

Intervention Promotion

• Studies should describe and evaluate efforts to promote awareness and use of tobacco cessation coverage. Evaluations of new or modified cessation benefits should include measurements to examine changes in benefit awareness among patients and providers as well as measurements to capture change in patient use of the cessation benefit.

Intervention Evaluation

• Assessments of new or modified cessation benefits should define and enumerate the covered population, and examine changes in awareness, use, and cessation using both rates and absolute counts. Effectiveness and economic comparisons should be based on the total number of tobacco users who successfully quit within a defined population, and not just on differences in quit rates.
• Reducing out-of-pocket costs for evidence-based cessation treatments might be one approach to reduce tobacco-related disparities among population groups with health care coverage (such as Medicaid clients). Additional studies could provide additional evidence on the effectiveness of these interventions by age, gender, socioeconomic status (SES), and race/ethnicity. Modeling studies could examine relative differences in population impact between new or modified cessation benefits and current or enhanced cessation treatments offered through quitlines (which can provide evidence-based cessation treatments to tobacco users without access to health care coverage or services.

Implementation Issues

• Studies should examine and describe barriers to client use of new or modified cessation benefits, and implement and evaluate efforts to reduce remaining barriers.
• Studies should examine and describe barriers to providers’ use of evidence-based cessation treatments for their patients who use tobacco.
• What are the effects on use and effectiveness when coverage for cessation medications is tied to participation in other treatments?

Economic Evaluation

• Economic assessments should include the costs of promotion and examine the economic implications of ROPC programs and policies based on the promotion effort.
• Studies could also examine costs, impact, and economic implications of cessation benefits in comparison with cessation services provided by quitlines.

• In 13 of the 18 included studies, evidence-based treatments provided at reduced out-of-pocket cost included both medications and counseling. In the remaining five studies, only medications were provided at no or reduced out-of-pocket cost.
• In the remaining five studies, only medications were provided at no or reduced out-of-pocket cost.
• Nine of the included studies were randomized controlled trials while the remaining studies were primarily a mix of cohort and time-series designs.
• Fifteen of the included studies were conducted in the United States, while the remaining studies were conducted in Germany, the Netherlands, and the United Kingdom.

Effectiveness Review

Analytic Framework

When starting an effectiveness review, the systematic review team develops an analytic framework. The analytic framework illustrates how the intervention approach is thought to affect public health. It guides the search for evidence and may be used to summarize the evidence collected. The analytic framework often includes intermediate outcomes, potential effect modifiers, potential harms, and potential additional benefits.

Effectiveness Review

Summary Evidence Table Effectiveness Review

Economic Review

Summary Evidence Table Economic Review

The number of studies and publications do not always correspond (e.g., a publication may include several studies or one study may be explained n several publications).

Effectiveness Review

Studies from the Updated Search Period (January 2000-July 2012)

Randomized Controlled Trials

Boyle RG, Solberg LI, Magnan S, Davidson G, Alesci NL. Does insurance coverage for drug therapy affect smoking cessation? Health Aff (Millwood) 2002;21(6):162-8.

Dey P, Foy R, Woodman M, Fullard B, Gibbs A. Should smoking cessation cost a packet? A pilot randomized controlled trial of the cost-effectiveness of distributing nicotine therapy free of charge. Br J Gen Pract 1999;49:127 8.

Halpin HA, McMenamin SB, Rideout J, Boyce-Smith G. The costs and effectiveness of different benefit designs for treating tobacco dependence: results from a randomized trial. Inquiry 2006 Spring;43(1):54-65.

Hughes JR, Wadland WC, Fenwick JW, Lewis J, Bickel WK. Effect of cost on the self-administration and efficacy of nicotine gum: a preliminary study. Prev Med 1991;20:486 96.

Joyce GF, Niaura R, Maglione M, Mongoven J, Larson-Rotter C, Coan J, Lapin P, Morton S. The effectiveness of covering smoking cessation services for medicare beneficiaries. Health Serv Res 2008;43(6):2106-23.

Kaper J, Wagena EJ, Willemsen MC, van Schayck CP. A randomized controlled trial to assess the effects of reimbursing the costs of smoking cessation therapy on sustained abstinence.Addiction 2006;101:1656 61.

Kaper J, Wagena EJ, Willemsen MC, van Schayck CP. Reimbursement for smoking cessation treatment may double the abstinence rate: results of a randomized trial. Addiction 2005;100:1012 20.

Schauffler HH, McMenamin S, Olson K, Boyce-Smitgh G, Rideout JA, Kamil J. Variations in treatment benefits influence smoking cessation: results of a randomized controlled trial.Tobacco Control 2001;10:175-80.

Solomon LJ, Scharoun GM, Flynn BS, Secker-Walker RH, Sepinwall D. Free nicotine patches plus proactive telephone peer support to help low-income women stop smoking. Prev Med 2000;31(1):68-74.

Twardella D, Brenner H. Effects of practitioner education, practitioner payment and reimbursement of patients’ drug costs on smoking cessation in primary care: a cluster randomised trial. Tobacco Control 2007;16:15-21.

Other Design Studies

Burns, ME, Rosenberg MA, Fiore MC. Use of a new comprehensive insurance benefit for smoking-cessation treatment. Prev Chronic Dis 2005:2(4):A15.

Cox JL, McKenna JP. Nicotine gum: does providing it free in a smoking cessation program alter success rates? J Fam Pract 1990;31(3):278-80.

Curry SJ, Grothaus LC, McAfee T, Pabiniak C. Use and cost effectiveness of smoking-cessation services under four insurance plans in a health maintenance organization. N Eng J Med 1998;339:673-9.

Johnson RE, Hollis JF, Stevens VJ, Woodson GT. Patterns of nicotine gum use in a health maintenance organization. DICP 1991;25:730-5.

Keller P, Christiansen B, Kim SY, Piper M, Redmond L, Adsit R, Fiore M. Increasing consumer demand among Medicaid enrollees for tobacco dependence treatment: the Wisconsin ”Medicaid Covers It” campaign. Am Journal Health Prom 2011:25(6):392-5.

Land T, Rigotti NA, Levy DE, Paskowsky M, Warner D, Kwass JA, Wetherell L, Keithly L. A longitudinal study of medicaid coverage for tobacco dependence treatments in Massachusetts and associated decreases in hospitalizations for cardiovascular disease. PLoS Med 2010 Dec7;7(12):e1000375.

Land T, Warner D, Paskowsky M, Cammaerts A, Wetherell L, Kaufmann R, Zhang L, Malarcher A, Pechacek T, Keithly L. Medicaid coverage for tobacco dependence treatments in Massachusetts and associated decreases in smoking prevalence. 2010 PLoS ONE5(3):e9770.doi:10.1371/journal.pone.0009770.

Petersen R, Garrett JM, Melvin CL, Hartmann KE. Medicaid reimbursement for prenatal smoking intervention influences quitting and cessation. Tobacco Control 2006;15(1):30-4.

Zeng F, Chen C-I, Mastey V, Zou KH, Harnett J, Patel BV. Effects of copayment on initiation of smoking cessation pharmacotherapy: an analysis of varenicline reversed claims. Clin Ther 2011;33:225-34.

Economic Review

Bertram MY, Lim SS, Wallace AL, Vos T. Costs and benefits of smoking cessation aids: making a case for public reimbursement of nicotine replacement therapy in Australia. Tobacco Control 2007;16(4):255-60.

Curry SJ, Grothaus LC, McAfee T, Pabiniak C. Use and cost effectiveness of smoking-cessation services under four insurance plans in a health maintenance organization. N Eng J Med 1998;339(10):673-9.

Halpern M, Khan Z, Young T, Battista C. Economic model of sustained-release bupropion hydrochloride in health plan and work site smoking-cessation programs. Am J Health Syst Pharm 2000;57(15):1421-9.

Halpern MT, Dirani R, Schmier JK. Impacts of a smoking cessation benefit among employed populations. J Occup Environ Med 2007;49(1):11-21.

Halpin HA, McMenamin SB, Rideout J, Boyce-Smith G. The costs and effectiveness of different benefit designs for treating tobacco dependence: results from a randomized trial. Inquiry 2006;43(1):54-65.

Hughes JR, Wadland WC, Fenwick JW, Lewis J, Bickel WK. Effect of cost on the self-administration and efficacy of nicotine gum: a preliminary study. Prev Med 1991;20(4):486-96.

Jackson KCI, Nahoopii R, Said Q, Dirani R, Brixner D. An employer-based cost-benefit analysis of a novel pharmacotherapy agent for smoking cessation. J Occup Environ Med 2007;49(4):453-60.

Javitz HS, Swan GE, Zbikowski SM, Curry SJ, McAfee TA, Decker D, et al. Return on investment of different combinations of bupropion SR dose and behavioral treatment for smoking cessation in a health care setting: an employer’s perspective. Value in Health 2004;7(5):535-43.

Joyce GF, Niaura R, Maglione M, Mongoven J, Larson-Rotter C, Coan J, et al. The effectiveness of covering smoking cessation services for Medicare beneficiaries.Health Serv Res 2008;43(6):2106-123.

Kaper J, Wagena EJ, van Schayck CP, Severens JL. Encouraging smokers to quit: the cost effectiveness of reimbursing the costs of smoking cessation treatment.Pharmacoeconomics 2006;24(5):453-64.

Levy DE. Employer-sponsored insurance coverage of smoking cessation treatments. Am J Manag Care 2006;12(9):553-62.

Nielsen K, Fiore M. Cost-benefit analysis of sustained-release bupropion, nicotine patch, or both for smoking cessation. Prev Med 2000;30(3):209-16.

Richard P, West K, Ku L. The return on investment of a Medicaid tobacco cessation program in Massachusetts.PloS One 2012;7(1):e29665.

Salize HJ, Merkel S, Reinhard I, Twardella D, Mann K, Brenner H. Cost-effective primary care-based strategies to improve smoking cessation: more value for money.Arch Intern Med 2009;169(3):230-5.

Schauffler HH, McMenamin S, Olson K, Boyce-Smith G, Rideout JA, Kamil J. Variations in treatment benefits influence smoking cessation: results of a randomised controlled trial. Tobacco Control 2001;10(2):175-80.

Tremblay M, Payette Y, Montreuil A. Use and reimbursement costs of smoking cessation medication under the Quebec public drug insurance plan. Can J Public Health 2010;100(6):417-20.

Vemer P, Rutten van M lken MP, Kaper J, Hoogenveen RT, Van Schayck C, Feenstra TL. If you try to stop smoking, should we pay for it? The cost utility of reimbursing smoking cessation support in the Netherlands. Addiction 2010;105(6):1088-097.

Warner KE, Mendez D, Smith DG. The financial implications of coverage of smoking cessation treatment by managed care organizations. Inquiry 2004;41(1):57-69.

Warner KE, Smith RJ, Smith DG, Fries BE. Health and economic implications of a work-site smoking-cessation program: a simulation analysis. J Occup Environ Med 1996;38(10):981-92.

Implementation Resource

Rural Health Information Hub, Tobacco Control and Prevention Toolkit
This toolkit compiles information, resources, and best practices to support development and implementation of tobacco control and prevention programs in rural communities. Modules include program models, implementation and evaluation resources, and funding and dissemination strategies.

• Reducing Out-Of-Pocket Costs for Evidence-Based Cessation Treatments

To update the evidence, the following databases were searched from January 2000 to July 2012 to identify English-language studies that assessed the effectiveness of interventions to reduce tobacco use and secondhand smoke exposure: Cochrane database, Embase, Medline, PsycINFO, PubMed. Intervention studies specific to this review were subsequently identified during the screening process.

Effectiveness Review

Search Strategy

Tobacco cessation [MeSH]

OR

((Title words: quit or quitting or quit line(s) or quitline(s) or abstinence or abstinent or stop or stopped or stopping or cessation or telephone or hotline(s)

OR

telephone[MeSH] or hotlines[MeSH])

AND

(Smoking[MeSH] or tobacco[MeSH] or tobacco, smokeless[MeSH] or tobacco use disorder[MeSH]

OR

Title words: cigar(s) or cigarette(s) or tobacco or tobaccos or hookah(s) or hubble-bubble or narghile or shisha or smokeless or snuff or snuffs or (waterpipe(s) and (tobacco or smoking or smoke)) or (pipe(s) and (smoke or smoking or tobacco)) )

Economic Review

The following economics databases were searched from January 2000 to July 2012 using the corresponding search strategies below.

Database: Centre for Reviews and Dissemination at the University of York

(tobacco or smoking or cigarette or cigarettes) AND (cost or costs or model* or benefit or utility or qaly or efficiency or dollar* or model* or reimburse* or price or pricing or priced or prices or economic* or tax or taxes or taxed) RESTRICT YR 2000-2012

Database: Web of Science Social Science Citation Index

Title=(tobacco or smoking or cigarette*) AND Title=(economic* or model* or taxes or tax or taxed or price* or pricing or cost or costs or utility or qaly or dollar* or efficiency or reimburse*) AND Language=(English) Timespan 2000-2012

Database: EconLit

(Tobacco or cigarette* or smoking) AND

(economics or cost or costs or benefit or benefits or utility or qaly or “quality-adjusted life year” or efficiency or dollar or dollars or “dynamic modeling” or “dynamic modelling” or reimbursement* or “simulation model*” or “price elasticity” or “economic impact” or media or television or broadcast* or radio or tv or “motion picture*” or films or movies or magazine* or newspaper* or “multimedia” or “multi media” or “mass communications*” or audiovisual or telecommunications or televised or campaign* or marketing or advertis* or label or labels or labeling or labeled or labeled or labeling or communit* or policy or policies or telephone or twitter or facebook or “social media” or access* or increase* or increasing or price* or prohibit* or assist* or restaurant or pub or pubs or disco or discos or bars or nightclub* or clubs or “public places” or “quality adjusted” or youth or child* or school* or student* or adolescent* or teen* or juvenile* or girls or boys or kids or minors or prevention or intervention* or program* or promotion or promoting or cessation or quitline* or helpline* or “quit line*” or workplace * or occupation* or psychology or reduc* or stop or stopping or quit or quitting or contest* or uptake or onset or start* or occupational or smokeless or “smoke-free” or smokefree or law or laws or ordinance* or regulat* or tax or taxed or taxes or taxing or fee or fees or jurisprudence or control* or legislat* or free or legal or model* or politic* or war or kick or habit* or coalition* or initiat*) Limit to English, 2000-2012

Database: JSTOR

(tobacco or smoking or cigarette or cigarettes) AND (cost or costs or model* or benefit or utility or qaly or efficiency or dollar* or model* or reimburse* or price or pricing or priced or prices or economic* or tax or taxes or taxed) RESTRICT YR 2000-2012

Hopkins DP, Briss PA, Ricard CM,Husten CG, Carande-Kulis VG, Fielding JE, Alao MO, McKenna JW, Sharp DJ, Harris JR, Woollery TA, Harris KW. Reviews of evidence regarding interventions to reduce tobacco use and exposure to environmental tobacco smoke. Am J Prev Med 2001;20(2S):16-66.

Fiore MC, Jaen CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville (MD): U.S. Department of Health and Human Services, Public Health Service. May 2008.

The following considerations are drawn from studies included in the evidence review, the broader literature, and expert opinion.

• Awareness of a new or improved cessation benefit among both clients and providers is essential for effective implementation.
  • In one Medicaid survey from 2000, cessation benefit awareness was only 36% among client tobacco users and only 60% among healthcare providers (McMenamin et al, 2004).
• The broader literature considered in this review identified a number of potential barriers to the implementation and use of these interventions.
  • Health systems, insurers, and plans may be concerned that establishing a cessation benefit will lead to abrupt or unpredictable increases in treatment use.
  • Both clients and their providers may be under-informed or confused about new or existing benefits, or find additional pre-authorization, prescription, or referral requirements as barriers to successful use.
• The Task Force also recommends quitline interventions. Quitlines and interventions to reduce client out-of-pocket costs have the potential to increase the use of evidence-based cessation treatments by tobacco users interested in quitting, and provide opportunities for both complementary coverage (quitlines are an accessible resource for tobacco users without access to health care services) and synergistic services (health care systems and providers can provide or encourage the use of quitline counseling as an additional component to their own cessation assistance).

Healthy People 2030

Healthy People 2030 includes the following objectives related to this CPSTF recommendation.

• Increase use of smoking cessation counseling and medication in adults who smoke — TU‑13
• Increase successful quit attempts in adults who smoke — TU‑14