Association Between Smoking Cessation Treatment and Healthcare Costs in a Single-Payer Public Healthcare System.

INTRODUCTION: There has been little investigation of whether the clinical effectiveness of smoking cessation treatments translates into differences in healthcare costs, using real-world cost data, to determine whether anticipated benefits of smoking cessation treatment are being realized. AIMS AND METHODS: We sought to determine the association between smoking cessation treatment and healthcare costs using linked administrative healthcare data. In total, 4752 patients who accessed a smoking cessation program in Ontario, Canada between July 2011 and December 2012 (treatment cohort) were each matched to a smoker who did not access these services (control cohort). The primary outcome was total healthcare costs in Canadian dollars, and secondary outcomes were sector-specific costs, from one year prior to the index date until December 31, 2017, or death. Costs were partitioned into four phases: pretreatment, treatment, posttreatment, and end-of-life for those who died. RESULTS: Among females, total healthcare costs were similar between cohorts in pretreatment and posttreatment phases, but higher for the treatment cohort during the treatment phase ($4,554 vs. $3,237, p < .001). Among males, total healthcare costs were higher in the treatment cohort during pretreatment ($3,911 vs. $2,784, p < .001), treatment ($4,533 vs. $3,105, p < .001) and posttreatment ($5,065 vs. $3,922, p = .001) phases. End-of-life costs did not differ. Healthcare sector-specific costs followed a similar pattern. CONCLUSIONS: Five-year healthcare costs were similar between females who participated in a treatment program versus those that did not, with a transient increase during the treatment phase only. Among males, treatment was associated with persistently higher healthcare costs. Further study is needed to address the implications with respect to long-term costs. IMPLICATIONS: The clinical effectiveness of pharmacological and behavioral smoking cessation treatments is well established, but whether such treatments are associated with healthcare costs, using real-world data, has received limited attention. Our findings suggest that the use of a smoking cessation treatment offered by their health system is associated with persistent higher healthcare costs among males but a transient increase among females. Given increasing access to evidence-based smoking cessation treatments is an important component in national tobacco control strategies, these data highlight the need for further exploration of the relations between smoking cessation treatment engagement and healthcare costs.

Variability in patient sociodemographics, clinical characteristics, and healthcare service utilization among 107,302 treatment seeking smokers in Ontario: A cross-sectional comparison.

BACKGROUND: Since 2005, the Smoking Treatment for Ontario Patients (STOP) program has provided smoking cessation treatment of varying form and intensity to smokers through 11 distinct treatment models, either in-person at partnering healthcare organizations or remotely via web or telephone. We aimed to characterize the patient populations reached by different treatment models. METHODS: We linked self-report data to health administrative databases to describe sociodemographics, physical and mental health comorbidity, healthcare utilization and costs. Our sample consisted of 107,302 patients who enrolled between 18Oct2005 and 31Mar2016, across 11 models operational during different time periods. RESULTS: Patient populations varied on sociodemographics, comorbidity burden, and healthcare usage. Enrollees in the Web-based model were youngest (median age: 39; IQR: 29-49), and enrollees in primary care-based Family Health Teams were oldest (median: 51; IQR: 40-60). Chronic Obstructive Pulmonary Disease and hypertension were the most common physical health comorbidities, twice as prevalent in Family Health Teams (32.3% and 30.8%) than in the direct-to-smoker (Web and Telephone) and Pharmacy models (13.5%-16.7% and 14.7%-17.7%). Depression, the most prevalent mental health diagnosis, was twice as prevalent in the Addiction Agency (52.1%) versus the Telephone model (25.3%). Median healthcare costs in the two years up to enrollment ranged from $1,787 in the Telephone model to $9,393 in the Addiction Agency model. DISCUSSION: While practitioner-mediated models in specialized and primary care settings reached smokers with more complex healthcare needs, alternative settings appear better suited to reach younger smokers before such comorbidities develop. Although Web and Telephone models were expected to have fewer barriers to access, they reached a lower proportion of patients in rural areas and of lower socioeconomic status. Findings suggest that in addition to population-based strategies, embedding smoking cessation treatment into existing healthcare settings that reach patient populations with varying disparities may enhance equitable access to treatment.

Public health impact of a novel smoking cessation outreach program in Ontario, Canada.

BACKGROUND: Provision of evidence-based smoking cessation treatment may contribute to health disparities if barriers to treatment are greater for more disadvantaged groups. We describe and evaluate the public health impact of a novel outreach program to improve access to smoking cessation treatment in Ontario, Canada. METHODS: We partnered with Public Health Units (PHUs) located across the province to deliver single-session workshops providing standardized evidence-based content and 10 weeks (2007-2008) or 5 weeks (2008-2016) of nicotine replacement therapy (NRT). Participants completed a baseline assessment and were followed up by phone or e-mail at 6 months. We used the RE-AIM (Reach, Effectiveness, Adoption, Implementation and Maintenance) framework to evaluate the public health impact of the program from 2007 to 2016. Given the iterative design and changes in implementation over time, data is presented annually or bi-annually. RESULTS: There were 26,122 enrollments from 2007 to 2016. Between 31 and 442 workshops were held annually. The annual reach was estimated to be 0.1-0.3% of eligible smokers in Ontario. Participants were older, smoked more heavily, had a lower household income, were more likely to be female and be diagnosed with a mood or anxiety disorder, and less likely to have a postsecondary degree compared to average Ontario smokers eligible for participation. The intervention was effective; at 6-month follow-up 22-33% of respondents reported abstinence from smoking. Adoption by PHUs was 81% by the second year of operation and remained high (72-97%) thereafter, with the exception of 2009-2010 (33-56%) when the program was temporarily unavailable to PHUs due to lack of funding. Implementation at the organizational level was not tracked; however, at the individual level, approximately half of participants used most or all of the NRT received. On average, maintenance of the program was high, with PHUs conducting workshops for 7 of the 10 years (2007-2016) and 4 of the 5 most recent years (2012-2016). CONCLUSIONS: The smoking cessation program had a high rate of adoption and maintenance, reached smokers over a large geographic area, including individuals more likely to experience disparities, and helped them make successful quit attempts. This novel model can be adopted in other jurisdictions with limited resources.

Concurrent E-Cigarette Use During Tobacco Dependence Treatment in Primary Care Settings: Association With Smoking Cessation at Three and Six Months.

INTRODUCTION: Electronic cigarettes (e-cigarettes) are being used as cessation aids by many smokers despite a lack of empirical evidence regarding their safety and efficacy. We analyzed the association of e-cigarette use and smoking abstinence in a population of smokers accessing standard smoking cessation treatment (nicotine replacement therapy [NRT] plus behavioral counseling) through primary care clinics in Ontario, Canada. METHODS: Participants were recruited through 187 primary care clinics across Ontario, Canada and were eligible for up to 26 weeks of brief behavioral counseling and individualized dosing of NRT at no cost. Adjusted logistic regression models were used to examine the association between concurrent e-cigarette use and smoking abstinence at 3- and 6-month follow-ups. RESULTS: Of the 6526 participants who completed a 3-month follow-up, 18.1% reported using an e-cigarette while in treatment. The majority of e-cigarette users (78.2%) reported using an e-cigarette for smoking cessation. At 3-month follow-up, e-cigarette use was negatively associated with abstinence after controlling for confounders (adjusted odds ratio [AOR] = 0.706, p < .001, 95% confidence interval [CI] = 0.607-0.820). E-cigarette use was also negatively associated with abstinence at 6-month follow-up (AOR = 0.502, p < .001, 95% CI = 0.393-0.640). CONCLUSION: E-cigarette use was negatively associated with successful quitting in this large community sample of smokers accessing standard evidence-based smoking cessation treatment through primary care clinics, even after adjusting for covariates such as severity of tobacco dependence, gender, and age. The findings suggest that concurrent use of e-cigarettes with NRT may harm cessation attempts. IMPLICATIONS: This study confirms previous findings from observational studies regarding the negative association between e-cigarette use and smoking cessation, but in a large cohort of smokers enrolled in an evidence-based treatment program. The implications of these findings are that concurrent use of e-cigarettes during a quit attempt utilizing cost-free evidence-based treatment (NRT plus behavioral counseling) does not confer any added benefit and may hamper successful quitting.

The relation between different dimensions of alcohol consumption and burden of disease: an overview.

AIMS: As part of a larger study to estimate the global burden of disease and injury attributable to alcohol: to evaluate the evidence for a causal impact of average volume of alcohol consumption and pattern of drinking on diseases and injuries; to quantify relationships identified as causal based on published meta-analyses; to separate the impact on mortality versus morbidity where possible; and to assess the impact of the quality of alcohol on burden of disease. METHODS: Systematic literature reviews were used to identify alcohol-related diseases, birth complications and injuries using standard epidemiological criteria to determine causality. The extent of the risk relations was taken from meta-analyses. RESULTS: Evidence of a causal impact of average volume of alcohol consumption was found for the following major diseases: tuberculosis, mouth, nasopharynx, other pharynx and oropharynx cancer, oesophageal cancer, colon and rectum cancer, liver cancer, female breast cancer, diabetes mellitus, alcohol use disorders, unipolar depressive disorders, epilepsy, hypertensive heart disease, ischaemic heart disease (IHD), ischaemic and haemorrhagic stroke, conduction disorders and other dysrhythmias, lower respiratory infections (pneumonia), cirrhosis of the liver, preterm birth complications and fetal alcohol syndrome. Dose-response relationships could be quantified for all disease categories except for depressive disorders, with the relative risk increasing with increased level of alcohol consumption for most diseases. Both average volume and drinking pattern were linked causally to IHD, fetal alcohol syndrome and unintentional and intentional injuries. For IHD, ischaemic stroke and diabetes mellitus beneficial effects were observed for patterns of light to moderate drinking without heavy drinking occasions (as defined by 60+ g pure alcohol per day). For several disease and injury categories, the effects were stronger on mortality compared to morbidity. There was insufficient evidence to establish whether quality of alcohol had a major impact on disease burden. CONCLUSIONS: Overall, these findings indicate that alcohol impacts many disease outcomes causally, both chronic and acute, and injuries. In addition, a pattern of heavy episodic drinking increases risk for some disease and all injury outcomes. Future studies need to address a number of methodological issues, especially the differential role of average volume versus drinking pattern, in order to obtain more accurate risk estimates and to understand more clearly the nature of alcohol-disease relationships.

The costs of alcohol, illegal drugs, and tobacco in Canada, 2002.

OBJECTIVE: The aim of this study was to estimate costs attributable to substance use and misuse in Canada in 2002. METHOD: Based on information about prevalence of exposure and risk relations for more than 80 disease categories, deaths, years of life lost, and hospitalizations attributable to substance use and misuse were estimated. In addition, substance-attributable fractions for criminal justice expenditures were derived. Indirect costs were estimated using a modified human capital approach. RESULTS: Costs of substance use and misuse totaled almost Can. $40 billion in 2002. The total cost per capita for substance use and misuse was about Can. $1,267: Can. $463 for alcohol, Can. $262 for illegal drugs, and Can. $541 for tobacco. Legal substances accounted for the vast majority of these costs (tobacco: almost 43% of total costs; alcohol: 37%). Indirect costs or productivity losses were the largest cost category (61%), followed by health care (22%) and law enforcement costs (14%). More than 40,000 people died in Canada in 2002 because of substance use and misuse: 37,209 deaths were attributable to tobacco, 4,258 were attributable to alcohol, and 1,695 were attributable to illegal drugs. A total of about 3.8 million hospital days were attributable to substance use and misuse, again mainly to tobacco. CONCLUSIONS: Substance use and misuse imposes a considerable economic toll on Canadian society and requires more preventive efforts.

Smoking-attributable morbidity: acute care hospital diagnoses and days of treatment in Canada, 2002.

BACKGROUND: Smoking is one of the most important risk factors for burden of disease. Our objective was to estimate the number of hospital diagnoses and days of treatment attributable to smoking for Canada, 2002. METHODS: Distribution of exposure was taken from a major national survey of Canada, the Canadian Community Health Survey. For chronic diseases, risk relations were taken from the published literature and combined with exposure to calculate age- and sex-specific smoking-attributable fractions (SAFs). For fire deaths, SAFs were taken directly from available statistics. Information on morbidity, with cause of illness coded according to the International Classification of Diseases version 10, was obtained from the Canadian Institute for Health Information. RESULTS: For Canada in 2002, 339,179 of all hospital diagnoses were estimated to be attributable to smoking and 2,210,155 acute care hospital days. Ischaemic heart disease was the largest single category in terms of hospital days accounting for 21 percent, followed by lung cancer at 9 percent. Smoking-attributable acute care hospital days cost over $2.5 billion in Canada in 2002. CONCLUSION: Since the last major project produced estimates of this type, the rate of hospital days per 100,000 population has decreased by 33.8 percent. Several possible factors may have contributed to the decline in the rate of smoking-attributable hospital days: a drop in smoking prevalence, a decline in overall hospital days, and a shift in distribution of disease categories. Smoking remains a significant health, social, and economic burden in Canada.

Alcohol-attributable morbidity and resulting health care costs in Canada in 2002: recommendations for policy and prevention.

OBJECTIVE: Alcohol is one of the most important risk factors for burden of disease, particularly in high-income countries such as Canada. The purpose of this article was to estimate the number of hospitalizations, hospital days, and the resulting costs attributable to alcohol for Canada in 2002. METHOD: Exposure distribution was taken from the Canadian Addiction Survey and corrected for per capita consumption from production and sales. For chronic disease, risk relations were taken from the published literature and combined with exposure to calculate age- and gender-specific alcohol-attributable fractions. For injury, alcohol-attributable fractions were taken directly from available statistics. Data on the most responsible diagnosis, length of stay for hospitalizations, and costs were obtained from the national Canadian databases. RESULTS: For Canada in 2002, there were 195,970 alcohol-related diagnoses among acute care hospitalizations, 2,058 alcohol-attributable psychiatric hospitalizations, and 183,589 alcohol-attributable admissions to specialized treatment centers. These accounted for 1,246,945 hospital days in acute care facilities, 54,114 hospital days in psychiatric hospitals, and 3,018,688 hospital days in specialized treatment centers (inpatient and outpatient). The main causes of alcohol-attributable morbidity were neuropsychiatric conditions, cardiovascular disease, and unintentional injuries. In total, Can. $2.29 billion were spent on alcohol-related health care. CONCLUSIONS: Alcohol poses a heavy burden of disease as well as a financial strain on Canadian society. However, there are evidence-based effective and cost-effective policy and legislative interventions as well as measures to better enforce these laws.

Illicit opioid use in Canada: comparing social, health, and drug use characteristics of untreated users in five cities (OPICAN study).

Most of the estimated 125,000 injection drug users (IDUs) in Canada use illicit opioids and are outside treatment (i.e., methadone maintenance treatment). Empirical data suggest that illicit opioid users outside treatment are characterized by various health and social problem characteristics, including polydrug use, physical and mental morbidity, social marginalization, and crime. Although required for evidence-based programming, systematic information on this specific substance-user population is sparse in Canada to date. This article presents and compares key characteristics of population of illicit opioid users outside treatment in five cities across Canada (OPICAN cohort). Overall, the majority of OPICAN participants regularly used both a variety of illicit opioids and cocaine or crack, reported physical and mental health (e.g., mood disorder) problems, lacked permanent housing, were involved in crime, and had their "ideal" treatment not available to them. However, key local sample differences were shown, including patterns of heroin versus prescription opioid use and levels of additional cocaine versus crack use as well as indicators of social marginalization. Illicit opioid user population across Canada differ on key social, health, and drug use indicators that are crucial for interventions and are often demonstrated between larger and smaller city sites. Differentiated interventions are required.