Current issues of ACP Journal Club are published in Annals of Internal Medicine


Economics

The nicotine patch was a cost-effective adjunct to smoking cessation

ACP J Club. 1996 Sept-Oct;125:53. doi:10.7326/ACPJC-1996-125-2-053


Source Citation

Fiscella K, Franks P. Cost-effectiveness of the transdermal nicotine patch as an adjunct to physicians' smoking cessation counseling. JAMA. 1996 Apr 24;275:1247-51.


Abstract

Objective

To determine the incremental cost-effectiveness of the transdermal nicotine patch in helping adults in primary care settings stop smoking.

Design

A decision analysis model from the perspective of the payer with effectiveness data taken from 2 meta-analyses of the effectiveness of physician counseling for smoking cessation; nicotine patch studies were included in 1 meta-analysis and excluded in the other.

Setting

The United States

Patients

Men and women 25 to 69 years of age who smoked and who received medical care in a primary care setting.

Intervention

The intervention assumed that all participants were counseled and given a prescription for the nicotine patch for smoking cessation and that half would agree to stop smoking and accept the prescription; of these patients, 95% would obtain nicotine patches.

Main costs and outcome measures

Quit rates with 1) physician counseling alone and 2) physician counseling and the nicotine patch were extracted from the meta-analyses. Costs involved in use of the nicotine patch included the extra time for counseling (5 min at US $80/h) and the actual cost of the patch ($112/mo for 2 mo). Relapse rates were taken from the National Health and Nutrition Examination Survey I and its follow-up study (35% after 1 y of abstinence). Future quit rates were taken from data from the Centers for Disease Control and Prevention. Quality-adjusted life-years (QALY) saved were calculated. Mortality data came from national databases and the American Cancer Society Cancer Prevention Study II.

Main results

Confirmed quit rates at 1 year were 2.5% for no intervention, 4.0% with physician counseling alone, and 7.9% with physician counseling plus the nicotine patch. The nicotine patch produced 1 additional lifetime quitter at a cost of $7332. The cost of each QALY saved depended on age and ranged from $4390 to $10 943 for men and from $4955 to $6983 for women. Sensitivity analysis showed that incremental cost-effectiveness of the patch remained relatively unaffected by changes in acceptance rate, refill rate, relapse rate, physician time, or retail markup of nicotine patch therapy. Cost-effectiveness was more sensitive to the baseline quit rate, the physician-counseling-only quit rate, and the discount rate. The cost-effectiveness of the patch was most sensitive to change in the quit odds ratio of the patch.

Conclusions

The addition of the nicotine patch to physician counseling for smoking cessation in primary care settings was relatively cost-effective. The cost of each quality-adjusted life year saved varied by age and sex of the participant.

Source of funding: No external funding.

For article reprint: Reprints not available.


Commentary

The study by Fiscella and Franks is the first published analysis of the long-term cost-effectiveness of using nicotine patches as an adjunct to physician counseling in reducing mortality from smoking. Despite the strong public health campaigns in many western societies, approximately 25% to 30% of the population continues to smoke. Most smokers who quit successfully do so unaided; only 10% seek some form of assistance. Brief, simple advice from health professionals can increase the 12-month quit rates by about 2.5% to 5%. Strong evidence is available from several meta-analyses that shows that the addition of nicotine patches further increases the odds of quitting by approximately 2-fold. Decisions about the availability and use of nicotine patches in routine practice, however, also need to take into account the costs associated with providing this therapy compared with alternative interventions that are designed to minimize morbidity and mortality.

This analysis, drawing on reliable sources of data, shows that the cost per QALY from using nicotine patches is substantially less than that of some commonly accepted preventive procedures, such as screening for hypertension. These results are particularly impressive because of the conservative nature of the estimates on which a number of the assumptions were made; in addition, the robustness of the cost-effectiveness estimates to variations in such factors as the quit rates without any intervention, the quit rates with brief counseling, or the quit rates with the nicotine patch. For the clinician, these results send a simple message: In addition to providing advice to smokers who seek assistance in quitting, it is cost-effective to offer nicotine patches regardless of the smoker's sex or age. The results also send the message to third-party payers that subsidizing short courses of nicotine patches is likely to be a worthwhile investment relative to other commonly used prevention strategies.

Chris Silagy, MBBS, PhD
Flinders University of South AustraliaBedford Park, South Australia, Australia