Cost-effectiveness of interventions to reduce tobacco smoking in the Netherlands. An application of the RIVM Chronic Disease Model

Introduction:Smoking is the most important single risk factor for mortality in the Netherlands and has been related to 12% of the burden of disease in Western Europe. Hence the Dutch Ministry of Health has asked to assess the cost-effectiveness of interventions to enhance smoking cessation in adults. Objective:To evaluate eight interventions for smoking cessation, namely increased tobacco taxes, mass media campaigns, minimal counseling, GP support, telephone counseling, minimal counseling plus nicotine replacement therapy, intensive counseling plus nicotine replacement therapy and intensive counseling plus bupropion. Methods: Costs per smoker were estimated based on bottom-up cost analysis. Combined with effectiveness data from meta-analyses and Dutch trials this gave us costs per quitter. To estimate costs per quality adjusted life year (QALY) gained, scenarios for each intervention were compared to current practice in the Netherlands. A dynamic population model, the RIVM Chronic Disease Model, was used to project future health gains and effects on health care costs. This model allows the repetitive application of increased cessation rates to a population with a changing demographic and risk factor mix, and accounts for risks of relapse and incidence of smoking related diseases that depend on time since cessation. Sensitivity analyses were performed for variations in costs, effects, time horizon, program size and discount rates. Results: A tax increase was the most efficient intervention with zero intervention costs from the health care perspective. Additional tax revenues resulting from a 20% tax increase were about 5 billion euro. Costs per smoker for a mass media campaign were relatively low (3 euro) and costs per QALY were below 10.000 euro.The effectiveness of these two population measures was uncertain. Costs per smoker for individual cessation support varied from 5 to almost 400 euro. Although all individual interventions had proven effectiveness, the cheapest intervention had an effect that did not differ significantly from current practice cessation rates. Compared to current practice, cost-effectiveness ratios varied between about 8,800 euro for structured GP stop-advice (H-MIS) to 21,500 euro for telephone counseling for implementation periods of 5 years. Discussion and conclusions: All smoking cessation interventions were cost-effective compared to current practice. Comparison of interventions is difficult, especially for population and individual interventions, because they are often applied in combination. Taking that into account, taxes seem to provide most value for money, especially since additional tax revenues outweigh the health care costs in life years gained.