The cost-effectiveness of tailored smoking cessation interventions for people with severe mental illness: a model-based economic evaluation.

Background: Tailored smoking cessation interventions, which combine behavioural and pharmaceutical support, are effective in populations with severe mental illness (SMI). We establish the cost-effectiveness of two tailored interventions in the UK: (i) a bespoke smoking cessation intervention (BSCI) versus usual care, and (ii) integrated tobacco cessation and mental health care (IC) versus standard smoking cessation clinic (SCC) referral. Methods: This economic evaluation was conducted between January 15th 2019 and August 4th 2022. We adapted a Markov model estimating smoking status, healthcare costs and quality-adjusted life years (QALYs) across the lifetime. Intervention effectiveness and costs were obtained from a systematic review and a meta-analysis. We obtained specific parameter values for populations with SMI for mortality, risk of smoking related comorbidities, and health utility. Uncertainty was analysed in deterministic and probabilistic sensitivity analysis (PSA). Findings: The BSCI was cost-effective versus usual care with an incremental cost-effectiveness ratio (ICER) of £3145 per QALY (incremental costs: £165; incremental QALYs: 0.05). Integrated care was cost-effective versus SCC with an ICER of £6875 per QALY (incremental costs: £292; incremental QALYs: 0.04). The BSCI and IC were cost-effective in 89% and 83% of PSA iterations respectively. The main area of uncertainty related to relapse rates. Interpretation: Our findings suggested that the tailored interventions were cost-effective and could increase QALYs and decrease expenditure on treating smoking related morbidities if offered to people with SMI. Funding: York Health Economics Consortium was funded by the National Institute for Health and Care Excellence to produce economic evaluations to inform public health guidelines.

Spotlight on tobacco guidance: NICE public health guidance update.

The updated NICE guidelines on tobacco recommend cost-effective and evidence-based interventions to prevent smoking initiation and promote smoking cessation across the life course. E-cigarettes are a cost-effective adjunct to support smoking cessation in adults, but their long-term effects are yet to be fully understood. Concerted efforts from healthcare and public health providers are required to reach underserved groups and hence address stark and longstanding inequalities in smoking prevalence and associated ill health in England.

How health inequalities accumulate and combine to affect treatment value: A distributional cost-effectiveness analysis of smoking cessation interventions.

INTRODUCTION: Reduction of health inequality is a goal in health policy, but commissioners lack information on how policies change health inequality. This study illustrates how decision models can be readily extended to produce information on health inequality impacts as well as for population health, using the example of smoking cessation therapies. METHODS: We retrospectively adapt a model developed for public health guidance to undertake distributional cost effectiveness analysis. We identify and incorporate evidence on how inputs vary by area-level deprivation. Therapies are evaluated in terms of total population health, extent of inequality, and a summary measure of equally distributed equivalent health based on a societal value for inequality aversion. Last, we examine how accounting for social variation in different sets of parameters affects our results. RESULTS: All interventions increase population health and increase the slope index ofinequality. At estimated levels of health inequality aversion for England, our resultsindicate that the increases in inequality are compensated by the health gains. DISCUSSION: The inequality impacts are driven by higher benefits of quitting and higher intervention uptake amongst advantaged groups, despite the greater proportion of smokers in disadvantaged groups. Failure to account for differential effects between groups leadsto different conclusions about health inequality impact but does not alter conclusionsabout value for money.

NICE UpdateNICE public health guidance update.

This article covers recent National Institute for Health and Care Excellence guidance and standards relevant to public health with a focus on behaviour change. The article summarizes recommendations for local commissioners and providers to help them tackle a range of behaviours including smoking, poor eating patterns, lack of physical activity and alcohol misuse.

Smoking Cessation: A Comparison of Two Model Structures.

BACKGROUND: Most economic evaluations of smoking cessation interventions have used cohort state-transition models. Discrete event simulations (DESs) have been proposed as a superior approach. OBJECTIVE: We developed a state-transition model and a DES using the discretely integrated condition event (DICE) framework and compared the cost-effectiveness results. We performed scenario analysis using the DES to explore the impact of alternative assumptions. METHODS: The models estimated the costs and quality-adjusted life years (QALYs) for the intervention and comparator from the perspective of the UK National Health Service and Personal Social Services over a lifetime horizon. The models considered five comorbidities: chronic obstructive pulmonary disease, myocardial infarction, coronary heart disease, stroke and lung cancer. The state-transition model used prevalence data, and the DES used incidence. The costs and utility inputs were the same between two models and consistent with those used in previous analyses for the National Institute for Health and Care Excellence. RESULTS: In the state-transition model, the intervention produced an additional 0.16 QALYs at a cost of £540, leading to an incremental cost-effectiveness ratio (ICER) of £3438. The comparable DES scenario produced an ICER of £5577. The ICER for the DES increased to £18,354 when long-term relapse was included. CONCLUSIONS: The model structures themselves did not influence smoking cessation cost-effectiveness results, but long-term assumptions did. When there is variation in long-term predictions between interventions, economic models need a structure that can reflect this.

The cost-effectiveness of seven behavioural interventions to prevent drug misuse in vulnerable populations.

BACKGROUND: The National Institute for Health and Care Excellence (NICE) developed a guideline on drug misuse prevention in vulnerable populations. Part of the guideline development process involved evaluating cost-effectiveness and determining which interventions represented good value for money. METHODS: Economic models were developed for seven interventions which aimed to prevent drug use in vulnerable populations. The models compared the costs (to the health and crime sectors) and health benefits (in quality-adjusted life years (QALYs)) of each intervention and its comparator. Sensitivity analysis explored the uncertainty associated with the cost of each intervention and duration of its effect. RESULTS: The reduction in drug use for each intervention partly offset the costs of the intervention, and improved health outcomes (QALYs). However, with high intervention costs and low QALY gains, none of the interventions were estimated to be cost-effective in the base case. Sensitivity analysis found that some of the interventions could be cost-effective if they could be delivered at a lower cost, or if the effect could be sustained for more than two years. CONCLUSIONS: For drug misuse prevention to be prioritised by funders, the consequences of drug misuse need to be understood, and interventions need to be shown to be effective and cost-effective. Quantifying the wider harms of drug misuse and wider benefits of prevention interventions poses challenges in evaluating the cost-effectiveness of drug misuse prevention interventions. A greater understanding of the consequences of drug misuse and causal factors could facilitate development of cost-effective interventions to prevent drug misuse.

Understanding perceived availability and importance of tobacco control interventions to inform European adoption of a UK economic model: a cross-sectional study.

BACKGROUND: The evidence on the extent to which stakeholders in different European countries agree with availability and importance of tobacco-control interventions is limited. This study assessed and compared stakeholders' views from five European countries and compared the perceived ranking of interventions with evidence-based ranking using cost-effectiveness data. METHODS: An interview survey (face-to-face, by phone or Skype) was conducted between April and July 2014 with five categories of stakeholders - decision makers, service purchasers, service providers, evidence generators and health promotion advocates - from Germany, Hungary, the Netherlands, Spain, and the United Kingdom. A list of potential stakeholders drawn from the research team's contacts and snowballing served as the sampling frame. An email invitation was sent to all stakeholders in this list and recruitment was based on positive replies. Respondents were asked to rate availability and importance of 30 tobacco control interventions. Kappa coefficients assessed agreement of stakeholders' views. A mean importance score for each intervention was used to rank the interventions. This ranking was compared with the ranking based on cost-effectiveness data from a published review. RESULTS: Ninety-three stakeholders (55.7% response rate) completed the survey: 18.3% were from Germany, 17.2% from Hungary, 30.1% from the Netherlands, 19.4% from Spain, and 15.1% from the UK. Of those, 31.2% were decision makers, 26.9% evidence generators, 19.4% service providers, 15.1% health-promotion advocates, and 7.5% purchasers of services/pharmaceutical products. Smoking restrictions in public areas were rated as the most important intervention (mean score = 1.89). The agreement on availability of interventions between the stakeholders was very low (kappa = 0.098; 95% CI = [0.085, 0.111] but the agreement on the importance of the interventions was fair (kappa = 0.239; 95% CI = [0.208, 0.253]). A correlation was found between availability and importance rankings for stage-based interventions. The importance ranking was not statistically concordant with the ranking based on published cost-effectiveness data (Kendall rank correlation coefficient = 0.40; p-value = 0.11; 95% CI = [- 0.09, 0.89]). CONCLUSIONS: The intrinsic differences in stakeholder views must be addressed while transferring economic evidence Europe-wide. Strong engagement with stakeholders, focussing on better communication, has a potential to mitigate this challenge.

Assessment of cost-effective changes to the current and potential provision of smoking cessation services: an analysis based on the EQUIPTMOD.

BACKGROUND AND AIMS: Increasing the reach of smoking cessation services and/or including new but effective medications to the current provision may provide significant health and economic benefits; the scale of such benefits is currently unknown. The aim of this study was to estimate the cost-effectiveness from a health-care perspective of viable national level changes in smoking cessation provision in the Netherlands and England. METHODS: A Markov-based state transition model [European study on Quantifying Utility of Investment in Protection from Tobacco model (EQUIPTMOD)] was used to estimate costs and benefits [expressed in quality-adjusted life years (QALY)] of changing the current provision of smoking cessation programmes in the Netherlands and England. The changes included: (a) increasing the reach of top-level services to increase potential quitters (e.g. brief physician advice); (b) increasing the reach of behavioural support (group-based therapy and SMS text-messaging support) to increase the success rates; (c) including a new but effective medication (cytisine); and (d) all changes implemented together (combined change). The costs and QALYs generated by those changes over 2, 5, 10 years and a life-time were compared with that of the current practice in each country. Results were expressed as incremental net benefit (INB) and incremental cost-effectiveness ratio (ICER). A sequential analysis from a life-time perspective was conducted to identify the optimal change. RESULTS: The combined change was dominant (cost-saving) over all alternative changes and over the current practice, in both countries. The combined change would generate an incremental net benefit of €11.47 (2 years) to €56.16 (life-time) per smoker in the Netherlands and €9.96 (2 years) to €60.72 (life-time) per smoker in England. The current practice was dominated by all alternative changes. CONCLUSION: Current provision of smoking cessation services in the Netherlands and England can benefit economically from the inclusion of cytisine and increasing the reach of brief physician advice, text-messaging support and group-based therapy.

Estimates of effectiveness and reach for 'return on investment' modelling of smoking cessation interventions using data from England.

BACKGROUND AND AIMS: Estimating 'return on investment' (ROI) from smoking cessation interventions requires reach and effectiveness parameters for interventions for use in economic models such as the EQUIPT ROI tool (http://roi.equipt.eu). This paper describes the derivation of these parameter estimates for England that can be adapted to create ROI models for use by other countries. METHODS: Estimates were derived for interventions in terms of their reach and effectiveness in: (1) promoting quit attempts and (2) improving the success of quit attempts (abstinence for at least 12 months). The sources were systematic reviews of efficacy supplemented by individual effectiveness evaluations and national surveys. FINDINGS: Quit attempt rates were estimated to be increased by the following percentages (with reach in parentheses): 20% by tax increases raising the cost of smoking 5% above the cost of living index (100%); 10% by enforced comprehensive indoor public smoking bans (100%); 3% by mass media campaigns achieving 400 gross rating points (100%); 40% by brief opportunistic physician advice (21%); and 110% by use of a licensed nicotine product to reduce cigarette consumption (12%). Quit success rates were estimated to be increased by the following ratios: 60% by single-form nicotine replacement therapy (NRT) (5%); 114% by NRT patch plus a faster-acting NRT (2%);124% by prescribed varenicline (5%); 60% by bupropion (1%); 100% by nortriptyline (0%), 10) 298% by cytisine (0%); 40% by individual face-to-face behavioural support (2%); 37% by telephone support (0.5%); 88% by group behavioural support (1%); 63% by text messaging (0.5%); and 19% by printed self-help materials (1%). There was insufficient evidence to obtain reliable, country-specific estimates for interventions such as websites, smartphone applications and e-cigarettes. CONCLUSIONS: Tax increases, indoor smoking bans, brief opportunistic physician advice and use of nicotine replacement therapy (NRT) for smoking reduction can all increase population quit attempt rates. Quit success rates can be increased by provision of NRT, varenicline, bupropion, nortriptyline, cytisine and behavioural support delivered through a variety of modalities. Parameter estimates for the effectiveness and reach of these interventions can contribute to return on investment estimates in support of national or regional policy decisions.

EQUIPT: protocol of a comparative effectiveness research study evaluating cross-context transferability of economic evidence on tobacco control.

INTRODUCTION: Tobacco smoking claims 700,000 lives every year in Europe and the cost of tobacco smoking in the EU is estimated between €98 and €130 billion annually; direct medical care costs and indirect costs such as workday losses each represent half of this amount. Policymakers all across Europe are in need of bespoke information on the economic and wider returns of investing in evidence-based tobacco control, including smoking cessation agendas. EQUIPT is designed to test the transferability of one such economic evidence base-the English Tobacco Return on Investment (ROI) tool-to other EU member states. METHODS AND ANALYSIS: EQUIPT is a multicentre, interdisciplinary comparative effectiveness research study in public health. The Tobacco ROI tool already developed in England by the National Institute for Health and Care Excellence (NICE) will be adapted to meet the needs of European decision-makers, following transferability criteria. Stakeholders' needs and intention to use ROI tools in sample countries (Germany, Hungary, Spain and the Netherlands) will be analysed through interviews and surveys and complemented by secondary analysis of the contextual and other factors. Informed by this contextual analysis, the next phase will develop country-specific ROI tools in sample countries using a mix of economic modelling and Visual Basic programming. The results from the country-specific ROI models will then be compared to derive policy proposals that are transferable to other EU states, from which a centralised web tool will be developed. This will then be made available to stakeholders to cater for different decision-making contexts across Europe. ETHICS AND DISSEMINATION: The Brunel University Ethics Committee and relevant authorities in each of the participating countries approved the protocol. EQUIPT has a dedicated work package on dissemination, focusing on stakeholders' communication needs. Results will be disseminated via peer-reviewed publications, e-learning resources and policy briefs.

Policy guidance on threats to legislative interventions in public health: a realist synthesis.

BACKGROUND: Legislation is one of the most powerful weapons for improving population health and is often used by policy and decision makers. Little research exists to guide them as to whether legislation is feasible and/or will succeed. We aimed to produce a coherent and transferable evidence based framework of threats to legislative interventions to assist the decision making process and to test this through the 'case study' of legislation to ban smoking in cars carrying children. METHODS: We conceptualised legislative interventions as a complex social interventions and so used the realist synthesis method to systematically review the literature for evidence. 99 articles were found through searches on five electronic databases (MEDLINE, HMIC, EMBASE, PsychINFO, Social Policy and Practice) and iterative purposive searching. Our initial searches sought any studies that contained information on smoking in vehicles carrying children. Throughout the review we continued where needed to search for additional studies of any type that would conceptually contribute to helping build and/or test our framework. RESULTS: Our framework identified a series of transferable threats to public health legislation. When applied to smoking bans in vehicles; problem misidentification; public support; opposition; and enforcement issues were particularly prominent threats. Our framework enabled us to understand and explain the nature of each threat and to infer the most likely outcome if such legislation were to be proposed in a jurisdiction where no such ban existed. Specifically, the micro-environment of a vehicle can contain highly hazardous levels of second hand smoke. Public support for such legislation is high amongst smokers and non-smokers and their underlying motivations were very similar - wanting to practice the Millian principle of protecting children from harm. Evidence indicated that the tobacco industry was not likely to oppose legislation and arguments that such a law would be 'unenforceable' were unfounded. CONCLUSION: It is possible to develop a coherent and transferable evidence based framework of the ideas and assumptions behind the threats to legislative intervention that may assist policy and decision makers to analyse and judge if legislation is feasible and/or likely to succeed.

Legislating for health: locating the evidence.

This article examines the timorous courtship between public health law and evidence-based policy. Legislation, in the form of direct prescriptions or proscriptions on behaviour, is perhaps the most powerful tool available to the public health policymaker. Increasingly, the same policymakers have striven to ensure that interventions are based soundly on a secure evidence base. The modern mantra is that the policies to follow are the ones that have been demonstrated to work. Legislative interventions, involving trade-offs between public benefit and private interests, present formidable challenges for the evaluator. Systematic reviews of their overall efficacy, the main tool of evidence-based policy, are in their infancy. The article presents a design for such reviews using the example of a forthcoming synthesis on the effectiveness of banning smoking in cars carrying children.

Best practice in smoking cessation services for pregnant women: results of a survey of three services reporting the highest national returns, and three beacon services.

AIMS: The NHS allocated dedicated funds to establish specialist smoking cessation services for pregnant smokers in England in 2000. An early survey revealed some uncertainty as to how the new services should work and monitor their outcome. The current survey focused on identifying examples of good practice in this difficult new field. METHOD: Three services with the highest number of successful four-week quitters reported for the 2003/4 monitoring year were identified from Department of Health (DH) monitoring records, and three services were nominated from those known in the field as examples of best practice. There was no overlap between the two groups. All six services provided in-depth interviews. RESULTS: All three highest ranking services that reported close to 100 per cent success rates included unaided quitters identified from hospital wards, rather then smokers actually treated. They had only minimal or average genuine treatment provision for pregnant smokers in place. The three beacon services far exceeded the national throughput and outcome average identified in the previous survey, and provided a wealth of useful information. Although they differed in staffing levels and other aspects of their activities, they all shared several key elements, including a systematic training of midwives in how to refer pregnant smokers, offering nicotine replacement treatment to almost all clients and having an efficient system of providing the prescriptions, offering flexible home visits, and providing intensive multi-session treatment delivered by a small number of dedicated staff. CONCLUSION: Smoking cessation services for pregnant women may need clearer guidance on what they are expected to provide, and how they should monitor their outcome. The key features of the beacon services can serve as a practical model of current best practice applicable across most PCTs.

GP prescribing of nicotine replacement and bupropion to aid smoking cessation in England and Wales.

AIMS: Prescribing nicotine replacement therapy (NRT) or bupropion for smoking cessation is of considerable importance to public health but little is known about prescribing practices. This paper examines general practitioners' (GPs') prescribing patterns in Britain where these drugs are reimbursed. The results have implications for other health-care systems considering introducing reimbursement. DESIGN, PARTICIPANTS AND SETTING: Postal survey conducted in 2002 of a random sample of 1088 GPs in England and Wales, of whom 642 (59%) responded. MEASURES: Number of requests GPs reported having received from patients for NRT and bupropion over the past month, the number of prescriptions they reported issuing and ratings of attitudes to these medications. FINDINGS: GPs reported receiving an average of 4.3 requests for NRT and 1.9 for bupropion in the previous month. They reported issuing 3.5 prescriptions for NRT and 1.2 for bupropion. Almost all GPs accepted that NRT (95%) and bupropion (97%) should be reimbursable on National Health Service (NHS) prescription. However, a significant minority of those who received requests for prescriptions did not issue any (8% for NRT and 26% for bupropion). This was related to whether they thought these products should be available on NHS prescription for both NRT and bupropion (OR = 0.66, P < 0.05), which in turn was related to beliefs about whether smokers should have to pay for treatment themselves, the cost-effectiveness of NRT/bupropion and the low priority they would give NRT/bupropion in the drug budget. For bupropion, concern about side-effects independently predicted not prescribing [odds ratio (OR) = 1.46, P < 0.03]. CONCLUSION: In the British health-care system, which has a well-established system for technology assessment and professionally endorsed guidelines, a significant minority of GPs decline all patient requests for stop-smoking medicines.

The nurse's role in promoting smoking cessation.

In this article the authors discuss strategies to help patients stop smoking--the greatest cause of preventable illness and premature death in the UK. They outline the various products and local support services available for patients.

Prevalence of hardcore smoking in England, and associated attitudes and beliefs: cross sectional study.

OBJECTIVE: To quantify the prevalence and characteristics of hardcore smokers in England. DESIGN: Cross sectional survey. SETTING: Interview in respondents' household. PARTICIPANTS: 7766 adult cigarette smokers. MAIN OUTCOME MEASURES: Hardcore smoking defined by four criteria (less than a day without cigarettes in the past five years; no attempt to quit in the past year; no desire to quit; no intention to quit), all of which had to be satisfied. RESULTS: Some 16% of all smokers were categorised as hardcore. Hardcore smoking was associated with nicotine dependence, socioeconomic deprivation, and age, rising from 5% in young adults aged 16-24 to 30% in those aged >or= 65 years. Hardcore smokers displayed distinctive attitudes towards and beliefs about smoking. In particular they were likely to deny that smoking affected their health or would do so in the future. Prevalence of hardcore smoking was almost four times higher than in California. CONCLUSION: Hardcore smoking presents a serious challenge to public health efforts to reduce the prevalence of smoking, but the proportion of hardcore smokers does not necessarily increase as overall prevalence in a population declines. More hardcore smokers could be persuaded to quit, but this will require interventions that are targeted to the particular needs and perceptions of both socially disadvantaged and older smokers.