“Categorically refusing to hire smokers is unethical,” that essay argues. In the case of a health provider, it’s also hypocritical, since doctors and nurses pledge to care for patients suffering from ailments brought on in part through their own bad behavior, the essay adds.
And it’s not like smokers necessarily have the power to quit. Both sides acknowledge that the majority of people who want to quit smoking are unable to do so. They each cite studies showing that aggressive smoking cessation programs can drastically increase a smoker’s chances of kicking the habit, but even the best programs fail 85% to 91% of the time.
One factor that makes it so hard is that the downsides of quitting – nicotine withdrawal, weight gain and the cost of gum and patches – are immediate, while the benefits – improved health, lower medical expenses – come later.
That’s another reason why it makes sense for employers to implement smoke-free hiring policies, according to the first essay – it offers an immediate benefit that helps “to counterbalance the costs of quitting.”
The other side remains unconvinced. These writers note that smokers are disproportionately poor, less educated and unemployed. Policies that cut them off from job opportunities and health insurance are thus a “double whammy,” they write.
Besides, plenty of nonsmoking employees make choices that affect the healthcare costs of their employers and make them less productive than their co-workers, the authors add. They have babies. They go rock climbing and break their arms.
“Promoting public health is a shared responsibility, and employers have a social obligation to contribute to the public health mission,” these authors conclude. “By cherry-picking ‘low-risk’ employees and denying employment to smokers, employers neglect this obligation, risk hurting vulnerable groups and behave unethically.”
The Cleveland Clinic sympathizers say it’s time for something more radical than sticking with the status quo. The 440,000 Americans who die due to tobacco each year outnumber the people who die as a result of homicides, suicides, car crashes, drug and alcohol use and HIV combined.
The solution is for more employers to join the Cleveland Clinic – and Baylor Health Care System, the University of Pennsylvania Health System, Union Pacific Railroad, Alaska Airlines, Scotts Miracle-Go and others – and implement no-smoking hiring policies of their own. There is much to gain by doing so, they write:
“The Cleveland Clinic moved to a smoke-free campus in 2005 and stopped hiring smokers in 2007. Reportedly, smoking rates decreased in Cuyahoga County (where the Cleveland Clinic is located) from 20.7% in 2005 to 15% in 2009, whereas the overall rate in the state decreased only from 22.4% to 20.3%.”
What do you think?
You can read both essays in full here and here on the New England Journal of Medicine website.
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According to the Campaign for Tobacco-Free Kids,46 the top five cigarette-consuming countries are China, Russia, United States, Japan, and Indonesia. China consumes more than 35% of the world’s cigarettes, with 53% of males smoking. Philip Morris International, British American Tobacco, Japan Tobacco International, and Imperial Tobacco are the world’s four largest multinational tobacco companies. The largest state tobacco monopoly is the China National Tobacco Corporation, which has the largest share of the global market among all companies. Based on WHO estimates, tobacco use costs the world an estimated $500 billion each year in health care expenditures, productivity losses, fire damage, and other costs. In the US alone, smoking causes more than $193 billion each year in health-related costs, including medical costs and the cost of lost productivity caused by smoking.5,47 New figures from the Campaign for Tobacco-Free Kids show that the social cost of smoking in the US could be estimated at about US$321 billion (ie both smoking-caused health costs of US$170 billion and associated productivity losses of US$151 billion).59 (See Fig. 2). This section examines the economic costs and benefits of smoking in some detail, citing examples from countries where tobacco is in high demand and use.
Smoking-attributable costs and benefits
As shown earlier, the costs of smoking can be classified into health-related costs and non-health-related costs.
The health care costs associated with tobacco-related illnesses are extremely high. In the United States, total annual public and private health care expenditures caused by smoking amount to approximately US$170 billion.59 Measured as a proportion of the gross domestic product (GDP), smoking costs in the US are approximately 1% of the GDP. Many studies have estimated the health-related costs of smoking. These costs include medical expenditure on drugs and administration, smoking-attributable morbidity and mortality, medical costs attributable to passive smoking, maternal smoking, and children smoking. Other direct costs include sickness/invalidity benefits attributable to tobacco abuse. A study by Yang et al48 reveals three ways in which smoking-attributable expenditures could be measured—average expenditure per inpatient hospitalization (or admission), average expenditure per outpatient visit, and self-medication expenditures. Some other indicators of health care expenditure include smoking-induced emergency and general practitioner visits for adults and children, and use of nursing homes and home-based care.49
Annual federal and state government smoking-caused Medicaid payments are estimated at US$39.6 billion (federal share: US$22.5 billion; states’ share: US$17.1 billion) (see Fig. 2). State-level estimates from USA revealed that the direct costs of smoking in California in 1999 were US$8.6 billion, with nearly half of this amount (47%) going to hospital care, 24% for ambulatory care, 15% for nursing home care, 13% for prescriptions, and 1% for domestic health care services.4 Fresh statistics from Campaign for Tobacco-Free Kids50 on state tobacco-related costs and revenues has revealed that smoking-related medical expenditures in US varied dramatically across states, with a low of US$22.4 million in Wyoming to a high of US$3.31 billion in New York. Another report by Armour et al51 showed that the proportion of health care expenditure attributable to smoking ranged between 6% and 18% across the different states.
The National Drug Strategy in Australia estimated the total social costs of smoking in Australia between 2004 and 2005 at about AUD$31.4 billion, representing 56.2% of total costs of drug abuse in Australia.16 Of these costs, AUD$12.02 billion or 38.2% was classified as tangible costs, while AUD$19.45 billion or 61.8% was intangible costs. Yang et al48 estimated the economic burden of smoking for 2008 in China at US$28.9 billion, representing 0.7% of China’s GDP and 3% of national health care expenditures. This figure also averaged US$127.30 per smoker. According to the study, mortality costs contributed the most to smoking-attributable costs in China, followed by outpatient expenditures. Results also show that, as a result of high prevalence rate, a whopping 93% of total economic cost of smoking in China was borne by men. Results from Hong Kong reveal that annual health-related cost of smoking in 1998 was US$688 million.49 The same study shows that about 5,596 deaths in Hong Kong among adults 35 years of age and above in 1998 was attributable to active smoking, while passive smoking accounted for 1,324 deaths. This brings to a total of 6,920 tobacco-related deaths out of 32,847 deaths. In what seems very surprising, passive smoking accounted for 23% of total smoking-related health care costs in Hong Kong, implying a growing risk of the prevalence of passive smoking. In Taiwan, the total smoking-attributable expenditures (SAEs) totaled US$397.6 million, representing 6.8% of the total medical expenditures for people aged 35 years and over.52 The mean annual medical expenditure per smoker was US$70 more than that of each nonsmoker.
Although the health risks associated with passive smokingd have been well documented in the literature, little is known about the economic costs. Regular exposure to second-hand smoke (SHS) among nonsmokers both at home and in the workplace could be economically costly in as much as it poses enormous health hazards. Following a recent research conducted by Plescia et al53 on SHS exposure in North Carolina, the total annual cost of treatment for conditions related to such exposure was estimated to be US$293.3 million in 2009. Though the majority of the SHS victims were children, the most common cases were traceable to cardiovascular conditions. In a similar study in Minnesota by Waters et al,54 the total annual cost of treatment for conditions associated with SHS was estimated to be US$228.7 million in 2008 dollars—equivalent to US$44.58 per Minnesota resident. Just as passive smoking poses huge health care costs, smoking during pregnancy, otherwise called “maternal smoking”, also has some related cost implications. It is associated with considerably higher child health expenditures as well as increase in overall medical costs.55 For example, the annual direct medical expenditure for early childhood respiratory illness attributable to maternal smoking totaled US$661 million for all children under the age of six.56 Further evidence reveals that smoking-attributable neonatal costs in the US represent almost US$367 million in 1996 dollars.57 Though these costs vary considerably from state to state, they can easily be avoided by implementing temporary cessation programs aimed at pregnant women.
The foregoing statistics indicate that smoking everywhere is very costly in many respects and takes a huge toll on public finances. For most countries, smoking-attributable costs represent the largest single expenditure in total health care costs, with wider implications for the economy.
Besides the health care costs of smoking, there are other costs that the abuse of tobacco imposes on society, and these costs need not be treated as less important. Tobacco-related illnesses and premature mortality impose high productivity costs to the economy because of sick workers and those who die prematurely during their working years. Lost economic opportunities in highly populated developing countries are likely to be particularly severe as tobacco use is high and growing in those areas.58 Countries that are net importers of tobacco leaf and tobacco products lose millions of dollars a year in foreign exchanges. Fire damage and the related costs are significant. In 2000, about 300,000 or 10% of all fire deaths worldwide were caused by smoking, and the estimated total cost of fires caused by smoking was US$27 billion.59 Tobacco production and use also damage the environment and divert agricultural land that could be used to grow food.
The economic loss to employers in the form of workplace absenteeism and the resulting lost productivity of their smoking employees is particularly alarming. In specific terms, employers suffer loss of revenue from the days off work and earnings lost from work owing to smoking-induced illness and premature death of its smoking employees during productive years. It is reported that US smokers are absent from work approximately 6.5 days more per year than nonsmokers. They make about six visits more to the health care centers per year than their nonsmoking counterparts, while dependents of smokers visit health care centers four times more than nonsmokers.23,56 Recent US statistics show that the total cost of productivity losses caused by smoking each year amounts to US$151 billion.47,59 This estimate only includes costs from productive work lives shortened by smoking-caused death, and does not include costs from smoking-caused disability during work lives, smoking-caused sick days, or smoking-caused productivity declines when at work, all of which amount to huge economic losses to the US. In California alone, the annual value of lost productivity owing to smoking-related illness between 2000 and 2004 averaged US$8.54 billion (US$6.87 billion for Florida; US$6.79 billion for Texas, and US$6.05 billion for New York), showing that these US states and many others have lost huge productive hours and potential revenue owing to smoking-induced health problems. These results suggest that, if adequate measures are taken by primary health authorities and employers to promote smoking cessation, there will be huge cost savings from smoking-related illnesses and premature deaths.
Absenteeism and premature deaths represent only a fraction of the aggregate indirect burden of smoking to employers. It may well be that even at work smoking-induced illness could retard the performance of smoking employees and translate into lost time and earnings, which may not be easily quantified. Arguing in this light, Thompson and Forbes60 noted that productivity losses emanating from smoking for the most part arise from short-term absenteeism or from performance at less than full efficiency due to respiratory problems or other smoking-induced illnesses. However, one cannot overlook the impact of other qualitative factors that lead to absenteeism and reduced productivity such as other health indicators (alcohol, weight, exercise, etc), job characteristics (occupation type, income, employment status, hours worked), and demographic characteristics (age, sex, ethnicity, marital status, education, place of work, etc). Evidence from Bush and Wooden61 revealed that, even after controlling for these factors, smoking was still highly correlated with work-place absenteeism. In fact, in their 1994 paper on the impact of smoking and alcohol on workplace absence, Bush and Wooden concluded that, after controlling for the effect of other variables, employees on smoking status were found to be 1.4 times more likely to be absent, and ex-smokers were found to be 1.3 times more likely to be absent than nonsmokers. Their results also showed that the probabilities of smoking-induced absenteeism differed considerably by sex. For male smokers, the probability of workplace absence surpassed that of male non-smokers by 1.7 times, while for female smokers the probability of absence fell slightly to 1.2 times more than those females who have never smoked.
Apart from smoking-attributable absenteeism, cigarette smoking and its associated activities can also be economically costly when they are the cause of fires. In the study conducted by Collins and Lapsley,17 the total cost of smoking-attributable fires in New South Wales, Australia, in 2006/2007 was estimated at AUD$51.4 million, with tangible costs representing over three-quarters of the total cost. In USA, smoking-induced fires lead to the death of 2,300 civilians (men, women, and children inclusive) per year, with additional 5,000 injuries per year.23,56 Besides the health care costs of treating injured or burn victims, direct property damaged from fires induced by tobacco has been valued at US$552 million per year. Other costs to employers of workers who smoke include health care claims and benefits not related to health care.23 There are also some hidden costs that are economically significant to society but often omitted in most studies for the lack of satisfactory data, eg, costs of paramedical and ambulance services, damage caused by smoking-induced forest fires, toxic effects from tobacco consumption, especially amongst children, as well as accidents and other property loss caused by cigarette smoking apart from fires.
Economic benefits of smoking
The cost of smoking notwithstanding, the tobacco industry poses a great deal of benefits, especially to the economy, consumers, and producers. It is therefore imperative to examine the positive economic effects of smoking and, hence, the impact or consequences on these of reducing smoking prevalence. Following previous studies by Thompson and Forbes,60 Woodfield,62 and Cohen and Barton,56 among others, the major benefits of smoking are in economic stimulation, namely income generated from production and consumption, tax yields, employment, and early death of smokers. Taxes on cigarettes have always contributed to government treasury. In 2009, President Barrack Obama signed an act that raised the US federal tax rate on cigarettes from 39 cents to US$1.01 per pack. The 156% tax increase was estimated to earn the US government about US$33 billion in tax over a 4½-year period. There are, however, economic consequences of raising taxes (see “The economics of policy-based interventions” Section).
The World Bank estimates that tobacco farming employs about 33 million people worldwide, and about 15 million of those workers reside in China alone.63 In China, over 4 million households rely on tobacco for their livelihood, as tobacco farmers, cigarette industry retailers, or employees.32 In fact, China is the largest producer and consumer of tobacco worldwide. All cigarettes are produced by the Chinese government’s tobacco monopoly company, which produces more than 1.7 trillion cigarettes annually. In 2003, the company generated almost US$2 billion in profits and taxes, while income from tobacco represented about 7.4% of centrally collected government revenue. In terms of consumption, China boasts of a smoking population of 350 million active smokers and 460 million passive smokers. In 2010, about 52.9% of Chinese men and 2.4% of women were current smokers.48 Given that China is the most populous country in the world, this proportion of smokers translates into enormous earning potential.
Apart from the income benefits of tobacco smoking, another source of benefit, especially to the government, of smoking is the substantial cost savings in pension payments from premature death of smokers. This is a highly debated issue in the literature, because it is premised on the thinking that a shorter life expectancy implies a reduced expenditure on pensions. Thus, attempts to promote this will be deemed socially undesirable and hence cannot be incorporated into social policy design.60,62
Clearly, from the above, therefore, if tobacco farming is to be phased out, many households, investors, and the government itself will suffer huge economic losses. Hence there is a need to strike a balance between the costs and benefits of smoking. But this is easier said than done, especially as the health implications of smoking far outweigh any associated economic returns from the perspective of a socially desirable outcome.
Effectiveness and cost effectiveness of smoking cessation interventions
Because the health hazards attributable to smoking are very significant, the risks of illness or disease are reduced following smoking-cessation interventions.19 According to a UK General Household Survey in 1998, about 27% of adults (aged 16 years and above) were smokers, and of this figure about 70% wanted to quit smoking. Data from a similar survey conducted in 1994 by the US health authorities indicated that 46.4% of smokers had made serious attempts to stop in the year preceding the survey, but only 5.7% of smokers managed to abstain from smoking after a period of 1 month or more, and only 2.5% of smokers are able to achieve permanent abstinence each year. The reason for this is smoking is an addiction and can hardly be stopped on the basis of will power alone. Evidence from Feenstra et al11 shows that only ~3%–7% of smokers who attempt to stop smoking on will power are still abstinent after 1 year. In order to enhance quit rates, there must be some deliberate measures to incentivize cessation. There are different forms of smoking cessation interventions, and they range from pharmacological treatment interventions to policy-based interventions, community-based cessation programs, TMT-based interventions, school-based interventions, and workplace- or employer-based interventions.
The aim of this section is to identify and evaluate cross-country evidence on the effectiveness and cost effectiveness of smoking cessation interventions. The idea of carrying out economic evaluations is to identify which interventions utilize the least resources or have greater cost savings, while being most effective in reducing both the number of smokers and the health- and non-health-related risks associated with smoking. By comparing the costs and outcomes of different alternative interventions, economic evaluations help health care professionals and policy makers in deciding the most efficient use of scarce resources.24 In estimating the effectiveness of cessation interventions, two major indicators are necessary: the number of long-term quitters and the health gains from smoking cessation, measured according to the age and sex of the quitters.19 In estimating the cost effectiveness of smoking cessation interventions, emphasis is placed on the impact of such interventions on direct cost reductions with respect to smoking-related morbidity and mortality rates as well as the effect on long-term medical expenditure.
Pharmacological treatment interventions
There are several pharmacological agents that are commonly used to aid smokers in their quest to quit smoking. However, we will concentrate on the three major types: nicotine replacement therapy (NRT), bupropion sustained release (SR), and varenicline. These treatment interventions are widely available on prescription, and in the case of NRT as an over-the-counter medication. They are licensed as first-line treatments for use as smoking-cessation aids in the US and the EU, and are widely recommended in many national guidelines.64
The aim of NRT is to temporarily replace much of the nicotine from cigarettes to reduce motivation to smoke and the physiological and psychological withdrawal symptoms often experienced during a quit attempt, thus easing the transition from cigarette smoking to complete abstinence. It is available in various forms and dosages, including transdermal patches (ie, absorbed slowly through the skin), as chewing gum, oral and nasal sprays, lozenges, sublingual tablets, and inhalers. NRT, in all its commercially available forms, has been found to help people who make a quit attempt to increase their chances of successfully stopping smoking. NRT increase the rate of quitting by as much as 50%–70% regardless of setting.65
Bupropion was developed as a non-tricyclic antidepressant, and is sometimes preferred by smokers who do not wish to use a nicotine-based treatment, or who have already failed to quit using NRT. The usual dose for smoking cessation is 150 mg once a day for 3 days, increasing to 150 mg twice a day, continued for 7–12 weeks.64 The quit attempt is generally initiated a week after starting pharmacotherapy. Some studies have shown that bupropion doses up to 300 mg per day does have significant effect in a dose–response fashion on smoking cessation, but does not seem to affect long-term cessation rates (see66).
Varenicline is a selective nicotinic receptor partial agonist, licensed as a prescription-only treatment for smoking cessation in USA in 2006 and in Europe in 2006/2007. The standard regimen is 1 mg twice a day for 12 weeks, with the first week titrated to reduce side effects, and quit date set for the second week. Varenicline has helped ~50% more people to quit than nicotine patch and “other” NRT (tablets, sprays, lozenges, and inhalers) and ~70% more people than nicotine gum.64 This means that for every 10 people who quit with NRT patch or with “other” NRT, about 15 could be expected to quit with varenicline, and for every 10 who quit with NRT gum, about 17 could be expected to quit with varenicline.
NRT, bupropion, and varenicline all improve the chances of quitting, with low risk of harms, and in some cases, using a combination of these pharmacological treatments could be seen to be even more clinically effective. However, as noted earlier, to justify the investment in any intervention, its effectiveness must be evaluated alongside its cost effectiveness. The cost effectiveness of pharmacological interventions is thus as important as their clinical effectiveness. A review of economic studies on these pharmacological treatment interventions (see Supplementary File 2) showed that varenicline and bupropion (with or without behavioral interventions) are more cost effective than NRT measures such as nicotine gum, patch, lozenge, and inhaler. A recent study by the Canadian Agency for Drugs and Technologies33 found that, if providers’ willingness to pay (WTP) was greater than US$10,000 per QALY gained, then varenicline was the optimal treatment of choice compared to NRT and bupropion.
Several studies have also found that the use of NRT and/or bupropion SR along with GP counseling is both clinical and cost effective in primary health care. For example, Stapleton et al67 showed that contingent prescriptions could yield additional life years at a cost between £398 (US$724) and £758 (US$1,380) in 1998 UK pounds compared to brief counseling alone. In a similar estimation of the cost effectiveness of treating nicotine dependence (including NRT and counseling), Croghan et al68 found the aggregate 1-year smoking rate to be 22% with a cost of $9,231 per net life year gained. This cost compares favorably with other medical services that rely only on GP counseling however brief or intensive. Although NRT products can be purchased over the counter, many people have suggested that free NRT treatments yield more positive results in terms of number of quitters than other cessation interventions. For example, Ong and Glantz69 found that in Minnesota, a free NRT program would generate 18,500 quitters at a cost of US$4,440 per quality of life adjusted years (QALY) compared to implementing a smoke-free workplace policy, which would generate 10,400 quitters at US$506 per QALY.
Nielsen and Fiore70 conducted a CBA of bupropion SR and nicotine transdermal patch (NTP) to see which of the two, or whether a combination of both, was more cost effective for smoking cessation. The results revealed that bupropion is more cost beneficial than either NTP or bupropion and NTP together, producing a net benefit in the first post-quit year of up to £338 per employee who attempts to quit compared with US $26 for NTP only, US$178 for the two combined, and US$258 for placebo, another pharmaceutical therapeutic that was used in the clinical trials. Thus, according to this study, bupropion is able to offer the most substantial monetary benefits than any other pharmacological treatment. In a more recent study by Bolin et al,31 the cost effectiveness of varenicline was compared with nicotine patches for smoking cessation in four European countries (Belgium, France, Sweden, and UK). Surprisingly, the results showed that the use of varenicline for smoking cessation was associated with reduced smoking-related morbidity and mortality more than was the case using NRT. The number of morbidities avoided per 1,000 smokers who made attempts to quit ranged from 9.7 in Belgium to 6.5 in UK. The number of QALY gained, per 1000 smokers, was 23 in Belgium, 19.5 in France, 29.9 in Sweden, and 23.7 in UK. The results of the base-case simulations revealed that, with the exception of France, varenicline treatment appeared to be more cost effective and cost saving than NRT. Thus, funding varenicline as a smoking cessation aid is an economically justifiable use of health care resources in these countries.
The economics of policy-based interventions
This subsection takes a look at the global evidence on the economic consequences of policy-based measures that aid smoking cessation. These include price-based measures (eg, increase in tobacco taxes, limitations on tobacco crop subsidies) and non-price measures (eg, no smoking regulations at work and in public places, restriction on sales to minors, and bans on promotion and advertising, etc). Legislative bans could either ban smoking completely (comprehensive) or restrict it to designated areas (partial). Both price-based measures and legislation-based smoking bans or restrictions have been found to yield both health and economic gains, including (1) reduction in smoking prevalence though reductions in the demand for and consumption of cigarettes, (2) significant reductions in the incidence of smoking-related diseases and deaths, (3) reduction in smoking-related medical costs, and (4) large gains in cumulative life years and QALYs.23,36,37,71–79
Increase in tobacco taxes
The most widely used measure to reduce the demand for tobacco is increase in taxes. This puts an upward pressure on tobacco prices, and higher tobacco prices tend to significantly reduce the consumption of tobacco.74,77 According to a World Bank report,63 when taxes are raised on tobacco, consumption decreases especially in young people; a 10% cigarette price increase results in a 7% decrease in smoking by young people and 4% by the general public. It has also been hypothesized that a price increase of 10% would reduce smoking by 4% in high-income countries and by about 8% in low-and middle-income countries.23,71 In other words, the price elasticity of demand for tobacco is higher in low- and middle-income countries and among populations of young or teenage smokers who are the most responsive to price changes. Smokers in high-income countries are, however, less responsive to price changes. According to Atkinson and Townsend,80 low price sensitivity means that the revenue argument against tax increases is rather unconvincing. As long as prices do not respond proportionately to tax increases (ie, price elasticity of less than 1), the revenue from tobacco will surely increase when taxes go up since “a fall in consumption is more than offset by the extra tax paid by those who continue to smoke” (pp. 492). Thus, according to Atkinson and Townsend, so long as the reduction in tobacco consumption is attributable to increased duty, the amount of corporate revenue from tobacco is likely to remain unaffected. The World Bank has recommended that “Governments increase tobacco tax to about 65% of retail price”.63 Increasing tobacco prices also increases the chances of cigarette theft, smuggling, and counterfeiting. The Mackinac Center on Public Policy estimates that profits made illegally from smuggling cigarettes to the US could amount to be between US$10 billion and US$17 billion.81 Over the years, tobacco tax increases have brought about increases in revenue for the government, even when the incidence of smuggling and tax evasion are discounted. Currently, in most high-income countries where tobacco control policies are very comprehensive, tobacco taxes represent between two-thirds and four-fifths of the retail price of cigarettes, whereas in low- and middle-income countries, they are generally below 50% of the total price.
Apart from the decline in tobacco consumption via increased prices, raising cigarette taxes also poses some potential health and cost-saving benefits. Reduced tobacco consumption leads to a reduction in health care costs as former smokers and their children do not require as much medical care or treatment as they used to.23 There is also another argument that says that huge tobacco taxes are equitable in the sense that it makes the tobacco industry pay more for the huge economic burden placed by its products to the health care system as well as the negative externalities of same to society. The income generated from tobacco taxes can also be used to finance community education and advertising against tobacco. In China, the largest producer and consumer of tobacco, a recent tobacco tax adjustment has just been implemented and, if this tax increase passes through to retail prices, it is expected to reduce the number of smokers by 630,000 saving 210,000 lives, at a price elasticity of −0.15.32 Following the same model, a tax increase of 1RMB (or US$0.13) per pack of cigarettes is expected to increase the revenue accruable to the Chinese government by 129 billion RMB (US$17.2 billion), reduce consumption by 3.0 billion packs of cigarettes, reduce the number of smokers by 3.42 million, and save 1.14 million lives. These figures indicate that tobacco tax increase in China can be construed as the most cost-effective measure of smoking cessation.
In summary, tobacco tax increases reduces tobacco consumption via higher cigarette prices, raises government revenue, saves more lives, preserves employment, and reduces tobacco farming. However, whether or not tax increases lead to loss of revenue in the tobacco industry is still a subject of debate, as smuggling and tax evasion help to minimize any losses arising from taxation.
Smoking restrictions in the work place and in public places
It is in recognition of the dangers of passive smoking that many governments institute no smoking restrictions in public places (eg, bars, restaurants, public buses, trains, airports, government buildings, and other public facilities) and private workplaces. Governments are now increasingly sensitive to the need to protect its citizens from the externalities caused by environmental tobacco smoke. Evidence from the US and Canada suggests that smoke-free air policies are associated with a significant reduction in cigarette consumption.23,71,82 In a report issued by the United States Environmental Protection Agency, the costs and benefits of a proposed national smoke-free environment act were modeled to identify its net benefits. The proposed policy was meant to curtail significantly smoking in public places entered by more than 10 people per week. The costs considered were costs of implementing and enforcing the restriction, costs of building and maintaining smoking lounges, among other costs. The benefits included savings from smoking-related medical expenditures, heart diseases averted, the value of lives saved, costs averted by a reduction in smoking-induced fires, and gains in productivity.83 The net present value to society was estimated to fall between US$42 and US$78 billion, and this range was obtained by considering high and low estimates of costs and benefits. In another study by the Stephens et al,82 they analyzed the relationship between cigarette prices and no-smoking bylaws to the prevalence of smoking in Canada. Results from a comparison of price and policy differences among Canadian provinces showed that the tendency of being a smoker falls with rising cigarette prices and with widespread no-smoking regulations, even after controlling for age, sex, education, and marital status of respondents. They thus concluded that no smoking regulations should be accompanied by an increase in cigarette prices to be more effective. If either were used in isolation, the outcomes will likely produce a lesser impact than the two measures used together.
Bans on tobacco advertisement
Tobacco remains the second most heavily advertised product in the United States besides the automobile industry.23 Over the years, it has been widely advocated that bans be placed totally on cigarette advertisements and promotional activities. In many countries, this bill has been a subject of controversy or debate. There are those who argue that a partial ban on advertisement has little or no effect on cigarette consumption.71,80 This is because, most adverts, particularly the tobacco-industry-related ones only reveal the brands smoked instead of the quantity smoked. In this sense, therefore, it is difficult to measure the impact of increased or reduced advertising on tobacco consumption. In addition, companies affected by such legislation could seek to utilize alternative forms of media. In an econometric study on high-income countries, Saffer and Chaloupka84 noted that comprehensive bans on tobacco advertising tend to reduce consumption.
Community-based intervention programs
Smoking cessation programs also come in the form of community-based interventions to educate, inform, and assist smokers in their quitting attempts. According to Secker-Walker et al,85 a community intervention is defined as “a co-ordinated, multi-dimensional programme aimed at changing adult smoking behaviour, involving several segments of the community and conducted in a defined geographical area, such as a town, city, country, or other administrative district” (pp. 3). These programs could range from community pharmacy-based interventions to group-based counseling, incentive-based smoking cessation contests, use of self-help quit smoking kit, and, in some cases, mass media campaigns directed at certain communities within a defined geographical area. The aim of this section is to identify and assess global evidence on the effectiveness and cost effectiveness of such interventions.
Nine studies on community-based interventions were reviewed, including studies by Altman et al,44 Secker-Walker et al,86 Stephens et al,82 Secker-Walker et al,87,88 Lightwood et al,89 Hurley and Matthews,26,30 and Simpson and Nonnemaker.90 Altman et al, as far back as 1987, studied the cost effectiveness and cost distribution of three community-based smoking cessation programs designed for use in the two education communities of the Stanford Five City Project. These programs included (1) smoking cessation class (eight 1-hour training sessions offered to ~8–25 participants where several quitting techniques were taught); (2) incentive-based smoking cessation contest (a 6-week community smoking cessation prize contest where entrants were assessed and rewarded on the basis of their smoking status and habits); and (3) self-help quit smoking kit (included tips on smoking replacement habits, social support available, public commitment, and record keeping and goal setting, among other tips aimed at providing specific actions to aid individual smoking cessation). Results revealed that the self-help quit had the lowest total cost (US$26,190), lowest quit rate (21%), lowest time requirement for participants, and was the most cost effective (with a CER of $50). However, the smoking cessation class was the most effective, requiring the most time from participants, with a quit rate of 35%, but incurring the highest total costs (US$261,589) and was also least cost effective (US$276). The smoking cessation contest was in-between the other two programs, with a total cost of US$82,925, a quit rate of 22%, and a CER of US$151.
A community pharmacy also provides an excellent setting in which to provide a smoking cessation program, as the pharmacy would have regular contact with residents of the area. Thavorn and Chaiyakunapruk30 evaluated the incremental cost effectiveness of a community-pharmacist-based smoking cessation (CPSC) in Thailand. They found that the CPSC program yielded cost savings and life year gains to the health system. A series of sensitivity analyses, however, demonstrated that both cost savings and life year gains were sensitive to variations in discount rate and long-term smoking quit rate associated with the intervention (see Supplementary File 2 for more details on the results).
Lightwood et al89 also examined the effect of California’s Tobacco Control Program (CTCP) on aggregate personal health expenditures in the state. The CTCP, which was established in 1989, offered a comprehensive approach to smoking cessation by altering the existing social norms and values among tobacco users. The campaign featured an aggressive media campaign with three themes, namely the tobacco industry lies, nicotine is addictive, and second-hand smoke kills. It also included a radical public policy change, especially in the area of promoting smoke free environments. The findings of the study revealed that, between 1989 and 2004, the California program led to a reduction in personal health care expenditures to the tune of US$86 billion (in 2004 dollars), which would have been expected without the program. Using 95% confidence interval, the cost savings ranged between $28 billion and US$151 billion.
Hurley and Matthews26 also presented evidence on the cost effectiveness of Australia’s National Tobacco Campaign (NTC), an intensive mass media antismoking campaign, which was launched in 1997. Using a quit benefits model (QBM), the study predicted that the NTC avoided more than 32,000 cases of COPD, 11,000 cases of acute myocardial infarction, 10,000 cases of lung cancer, and 2,500 cases of stroke. The model also predicted the prevention of about 55,000 deaths, 323,000 life-years gain, and 407,000 QALYs, as well as a health care cost savings of AUD$740.6 million. Thus, the NTC was both effective and cost saving.
The above studies as well as other community-based interventions all reveal that a strong and aggressive tobacco control program do not only reduce the number of smokers and its resulting health benefits but also reduce substantially the health care expenditure associated with smoking prevalence. It is worth noting that the benefits of these initiatives may not have been well established quantitatively in the sense that most of these studies reflect potential uncertainty in the estimates and data used as well as differences in the parameters estimated. In some cases, data sufficient to establish definite causality are also lacking. However, on the balance, the community-based cessation initiatives examined appear to yield substantial net benefits.
Telecoms, media, and technology-based interventions
TMT-based interventions refer to electronic and mass media-related means aimed at offering support to effect changes in smoking behavior in adults and young adolescents. Examples include telephone counseling offered through “quitlines” or “helplines”; radio, TV, and print media; and computer and Internet-based intervention programs. A summary of the results of related TMT-based cost effectiveness studies can be found in Supplementary File 2.
Telephone counselling, quitlines and text messaging
Telephone services can provide information and support for smokers. Counseling may be provided proactively or offered reactively to callers to smoking cessation helplines.91 Support can be given in individual counseling sessions or in a group therapy where clients can share problems and derive support from one another. Counseling may be helpful in planning a quit attempt and could assist in preventing relapse during the initial period of abstinence. Although intensive face-to-face intervention increases quit rates, there are difficulties in delivering it to large numbers. Telephone counseling may be a way of providing individual counseling more affordably.
Tomson et al45