Theme articleRepeated Tobacco-Use Screening and Intervention in Clinical Practice: Health Impact and Cost Effectiveness
Introduction
Tobacco use is the most important and frequent cause of death, morbidity, and healthcare costs, causing 435,000 deaths in the United States, or 18.1% of the total in 2000.1 Published evidence and the 2000 Public Health Service (PHS) guideline confirm that identifying smokers and providing them with brief advice and cessation assistance in clinical practice are both very effective and cost effective.2 The Guide to Community Preventive Services has strongly recommended multicomponent efforts to improve the delivery of brief primary care clinical cessation support, based on its review of the evidence.3
Most importantly for this analysis, the U.S. Preventive Services Task Force (USPSTF)4 in 2003 said that it “strongly recommends that clinicians screen all adults for tobacco use and provide tobacco-cessation interventions for those who use tobacco products (A Recommendation).” The Task Force “found good evidence that brief smoking cessation interventions, including screening, brief behavioral counseling (less than 3 minutes), and pharmacotherapy delivered in primary care settings, are effective in increasing the proportion of smokers who successfully quit smoking and remain abstinent after 1 year.” This is the only USPSTF counseling recommendation with an A rating.
The problem is that despite an increase in the delivery of smoking-cessation services, the level of service in medical practice is still well below the optimum level. The specific behaviors recommended in the PHS guideline are known as the 5A’s for: ask about tobacco use at every visit, advise to quit, assess willingness to make a quit attempt, assist with counseling and pharmacotherapy, and arrange follow-up.2 National benchmark rates are those provided by nonprofit staff-model health plans—and they show considerably higher rates of cessation advice than assistance. In a recent study, while 71% of 4207 smokers enrolled in such plans reported that they had been advised to quit at least once over the past year, 56% were assessed, 49% received some form of assistance, only 38% were offered pharmacotherapy, and only 9% received a recommendation for follow-up.5 Since most members make at least three to four office visits per year, the actual rates of these actions at each visit are clearly much less. It is also helpful to know that 68% of these smokers reported intending to quit in the next 6 months, 27% had asked for help with quitting, and 82% wanted their physicians to discuss smoking cessation often or at every visit. National data from Health Plan Employer Data and Information Set (HEDIS) or the National Health Interview Survey show much lower rates.6, 7 More typical of rates in most practices are those reported by smokers in the Community Intervention Trial for Smoking Cessation (COMMIT) community trial, with 75% reporting being asked, 49% advised, and 25% offered pharmacotherapy in the past year.8 Thus, there is ample room and need for improvement.
Although there are many published studies of the effectiveness of various smoking-cessation interventions in the literature and almost as many studies of their cost effectiveness, these two issues have not been addressed simultaneously, and none has studied the long-term effects of the repeated counseling interventions recommended by the USPSTF and the PHS. Moreover, these studies have not been performed in a way that would permit direct comparison of their results with the other preventive services recommended by the USPSTF. With the exception of a single study of providing insurance coverage for bupropion,9 the literature assesses the cost effectiveness of one-time interventions,10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37 although in practice, cessation counseling should be delivered repeatedly over multiple years for continuing smokers. Other services, such as cancer screening and childhood immunizations, are evaluated on the basis of repeated interventions at recommended intervals, not on the basis of a one-time intervention. In addition, the vast majority of cost-effectiveness estimates in U.S. populations exclude the cost savings from prevented tobacco-attributable illness,9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 20, 21, 22, 25 although that is rarely the case for other preventive services. Although data on the effectiveness of repeated counseling are limited, providing the best possible analysis of the health benefits and cost-effectiveness of repeated tobacco-use screening and intervention is necessary to provide decision makers with information that is comparable to that available for other recommended preventive services. This update with improved methods to Partnership for Prevention’s 2001 ranking of 30 clinical preventive services is important for its potential to better understand the comparative value of tobacco-cessation interventions and thereby to stimulate greater efforts to improve delivery rates.38 Using new data and a more detailed model than was used for the 2001 ranking, this article presents the details of new estimates of the clinically preventable burden (CPB) and cost effectiveness of tobacco-use screening and brief interventions for the companion article that ranks USPSTF clinical preventive services.39
Section snippets
Methods
A detailed description of the generic study methods is also available in a companion article and a more detailed technical report is available online.38, 40, 41 These methods were designed to ensure consistency in calculating the two components of the estimate used in the ranking: (1) CPB as a measure of health impact and (2) cost effectiveness of delivering each service. This section focuses on the specific methodologic issues for each calculation that are unique to repeated tobacco-use
Results
Table 2 shows results for the four models. The results of Models 1 and 2, with effectiveness of one-time counseling, produced a CPB of 190,000 QALYs—a large enough health impact to be among the top half for evidence-based preventive services. Models 3 and 4, based on the effectiveness of repeated counseling, produced a CPB of 2.47 million QALYs—a large enough health impact to be among the top three evidence-based preventive services.
Model 1 most closely resembles existing estimates of the cost
Discussion
Applying these standardized methods for calculating CPB and cost effectiveness results in such high estimates that smoking-cessation counseling with offers of medication prescription is clearly one of the most important clinical preventive services, even at the seemingly low rate of effectiveness at 12 months of 2.4% to 5.0%. Measured as percent of burden of disease prevented, the cumulative effectiveness of repeated annual tobacco-use screening and intervention may be similar to that of annual
References (109)
- et al.
Tobacco-cessation services and patient satisfaction in nine nonprofit HMOs
Am J Prev Med
(2005) - et al.
Under-use of smoking-cessation treatmentsresults from the National Health Interview Survey, 2000
Am J Prev Med
(2005) - et al.
Cost-effectiveness of treating nicotine dependencethe Mayo Clinic experience
Mayo Clin Proc
(1997) - et al.
Cost-benefit analysis of sustained-release bupropion, nicotine patch, or both for smoking cessation
Prev Med
(2000) - et al.
The cost-effectiveness of the nicotine transdermal patch for smoking cessation
Prev Med
(1997) - et al.
Cost-effectiveness analysis of a family physician delivered smoking cessation program
Prev Med
(2000) - et al.
Cost-effectiveness of smoking cessation modalitiescomparing apples with oranges?
Prev Med
(1996) - et al.
Prescription of transdermal nicotine patches for smoking cessation in general practiceevaluation of cost-effectiveness
Lancet
(1999) - et al.
Priorities among recommended clinical preventive services
Am J Prev Med
(2001) - et al.
Priorities among effective clinical preventive servicesresults of a systematic review and analysis
Am J Prev Med
(2006)