Theme article
Repeated Tobacco-Use Screening and Intervention in Clinical Practice: Health Impact and Cost Effectiveness

https://doi.org/10.1016/j.amepre.2006.03.013Get rights and content

Background

This report updates 2001 estimates of disease burden prevented and cost effectiveness of tobacco-use screening and brief intervention relative to that of other clinical preventive services. It also addresses repeated counseling because the literature has focused on single episodes of treatment, while in reality that is neither desirable nor likely.

Methods

Literature searches led to four models for calculating the clinically preventable burden of deaths and morbidity from smoking as well as the cost effectiveness of providing the service annually over time. The same methods were used in similar calculations for other preventive services to facilitate comparison.

Results

Using methods consistent with existing literature for this service, an estimated 190,000 undiscounted quality-adjusted life years (QALYs) are saved at a cost of $1100 per QALY saved (discounted). These estimates exclude financial savings from smoking-attributable disease prevented and use the average 12-month quit rate in clinical practice for tobacco screening and brief cessation counseling with cessation medications (5.0%) and without (2.4%). Including the savings of prevented smoking-attributable disease and using the effectiveness of repeated interventions over the lifetime of smokers (23.1%), 2.47 million QALYs are saved at a cost savings of $500 per smoker who receives the service.

Conclusions

This analysis makes repeated clinical tobacco-cessation counseling one of the three most important and cost-effective preventive services that can be provided in medical practice. Greater efforts are needed to achieve more of this potential value by increasing current low levels of performance.

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

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