AHCPR Smoking Interventions Are Cost Effective

NEW YORK—The smoking cessation interventions outlined in the Agency for Health Care Policy and Research (AHCPR) Smoking Cessation Clinical Practice Guideline are more cost effective than many other preventive interventions such as mammography or cholesterol treatment, Michael Fiore, MD, MPH, said at a briefing sponsored by the American Medical Association and the American Public Health Association.

“Our study confirms that there is not a single other preventive intervention a doctor can provide to all adult patients that will be as cost effective as smoking cessation treatment,” Dr. Fiore said. The only intervention that rivals smoking cessation for “return on investment,” he said, is childhood immunizations.

Dr. Fiore, director of the Center for Tobacco Research and Intervention, University of Wisconsin Medical School, said that smoking is the direct cause of approximately $50 billion in direct medical expenses—about 10% of the total health care bill in America.

“Given that there are about 50 million smokers—we now can estimate that roughly $1 billion can be saved in direct health care costs each year for every million smokers who successfully quit.” Effective smoking cessation treatments cost about $2,500 per year of life saved, compared with mammography screening, at about $50,000/year of life saved, or cholesterol treatments at $100,000, he said.

The evidence-based AHCPR Guideline, released in 1996, identified efficacious interventions for primary care clinicians and smoking cessation specialty providers (see table).

The study by Dr. Fiore and colleagues (Cromwell et al: JAMA, Dec. 3, 1997) found that individual counseling or group counseling when combined with the nicotine patch as adjuvant therapy is the most cost-effective way to stop smoking, suggesting that greater spending on interventions yields more net benefit.

Three-Minute Intervention

Dr. Fiore explained how, in as little as 3 minutes, clinicians can intervene with their patients who smoke and implement a smoking cessation program. The most important elements of such an intervention are providing social support, cessation skills, and nicotine replacement therapy—the patch, gum, and nasal spray— or non-nicotine medicines such as bupropion (Zyban).

He outlined a simple five-point plan for quitting: (1) Help the patient set a quit date; (2) stress to the patient the importance of total abstinence from tobacco; (3) review with the patient any past quit attempts and why they failed; (4) anticipate challenges or barriers to success; and (5) help the patient come up with a plan to deal with the challenges. He noted, for example, that 50% of smokers relapse with some alcohol in their system.

Summary of AHCPR Smoking Cessation Practice Guideline

Recommendations for physicians

Recommendations for smoking cessation specialists

Dr. Fiore found that it would cost $6.3 billion, or $32.31 per capita, to implement the guideline the first year. About 1.7 million smokers would quit over the current baseline and could expect to enjoy 2.4 million extra years of life.

To help implement such a widespread program, Dr. Fiore suggests mandating that all insurance plans provide coverage for the smoking-cessation counseling and pharmacotherapy treatments outlined in the AHCPR Smoking Cessation Guideline, supplemented by the recently FDA-approved agent for smoking cessation.

“Why is it,” he asked “that insurance plans consistently pay tens of thousands of dollars for the outcomes of smoking, whether it be heart attacks, strokes, cancer, or emphysema, but most will pay nothing to avoid these expenses?”

People who quit on their own have about a 7% success rate. “With a brief program provided to everyone, the long-term quit rate could be increased to 15% to 30%,” he said, “not a bad success rate, for what is, in effect, a chronic disease.”