Tobacco control interventions are an excellent investment. A review of economic evaluations of tobacco control programs published in 2009 concluded: ‘the existing studies show in almost every case that tobacco control programs and policies are either cost-saving or highly cost-effective’.1 A 2010 Australian report that examined the cost-effectiveness of 150 disease prevention interventions predicted that a tobacco taxation increase (of 30%) would not only be cost-saving, but was the intervention that would have the highest health benefit—270,000 DALYs prevented.2
The following sections summarise studies that have investigated the cost-effectiveness of tobacco control per se ( 17.4.1) and studies on the cost-effectiveness of specific policy interventions ( 17.4.2), population-based strategies ( 17.4.3) and clinical interventions ( 17.4.4).
17.4.1 The cost-effectiveness of tobacco control per se
The cost-effectiveness of tobacco control per se has been studied in the following four types of analyses:
Economic evaluations of programs (actual or proposed) that involved a mix of interventions—for example, the California Tobacco Control program, which included taxation increases, legislation mandating smoke-free public places, mass media anti-smoking campaigns and community and school-based prevention programs.
Studies that compare different communities in terms of their tobacco control expenditures and the resulting outcomes (smoking rates, health outcomes or economic outcomes). These studies are a type of epidemiological study referred to as ‘ecological analyses’, because the unit of analysis is a population rather than an individual.
Studies of the impact of projected reductions in smoking prevalence on specific health or economic outcomes. Although comprehensive evaluations are informative, analyses that focus on specific outcomes, such as hospitalisations avoided through reduced smoking, can aid stakeholders’ understanding of the benefits of tobacco control.
188.8.131.52 Evaluations of comprehensive tobacco control programs
The largest comprehensive tobacco control program in the world to date is the California Tobacco Control Program (CTCP).3 It began in 1989, with an annual budget of about $100 million. In addition to the tobacco tax increase that financed the program, the CTCP involved an anti-tobacco media campaign and community- and school-based interventions.4 As well as directly encouraging people to quit, the CTCP has included vigorous efforts to discourage smoking around others, backed up by some of the most far-reaching legislation seen anywhere in the world mandating smokefree public places. Changing social norms about smoking has also been shown to have contributed to the dramatic decline of smoking in California.5 An economic evaluation investigated the impact of tobacco control on Californian men alive in 1990 over their subsequent life until 2079, when the youngest would turn 90. The value of the net health care savings and years of life saved was about $22 million (in 1990 dollars, discount rate of 3% per annum).6 So the CTCP was cost saving as well as effective.
The consulting group Applied Economics evaluated the return on investment in Australian public health programs.7 They found that from the late 1960s to late 1990s male smoking rates dropped from 45 to 27% and female rates dropped from 30 to 23%. By 1996, tobacco expenditure per capita had dropped to less than 40% of its 1965 level. Applied Economics estimated that Australian public health programs aimed at reducing tobacco consumption had cost $176 million over that 30-year period. Based on estimated reductions in disease and about half a million premature deaths up to the year 2000, the study estimated that tobacco control interventions had saved the Australian economy $8.06 billion (2000 dollars, discounted back to 1971). The analysis found that the government saved $2 for every $1 it spent on public health programs to reduce smoking.
184.108.40.206 Ecological analyses of tobacco control
The 1998 Master Settlement Agreement with the tobacco industry in the US made funding available to states for tobacco control programs. Implementation of such programs has varied between states.8 It is therefore feasible to investigate the correlation, at state level, between tobacco control expenditure and health and health economic outcomes. Such analyses have found that in states that increased tobacco control program funding there were decreases in aggregate cigarette sales,8 lower prevalence of youth smoking,9 more rapid falls in cardiovascular death rates10 and reduced personal health care expenditures.11
220.127.116.11 Evaluations of the benefit of smoking prevalence reductions
Several Australian analyses have modelled the impact of reduced smoking on specific health economic outcomes. The first analysis was published in 2004,12 in the context of the federal government’s Intergenerational Report (IGR) which predicted large increases in the cost of government subsidies of medicines under the Pharmaceutical Benefits Scheme (PBS) consequential to an ageing population.13 The economic analysis predicted that if smoking prevalence were reduced by 5%, savings in PBS subsidies for drugs to treat smoking-related cardiovascular disease would exceed a billion dollars over the 40-year period of the IGR. If the 5% reduction in smoking rate could be achieved at a cost of $45 million, the program would have an internal rate of return of 33% and the initial investment would be recouped in eight years.
The second analysis investigated the impact of reductions in the smoking rate on acute myocardial infarction hospitalisations and costs.14 A model previously used to predict these outcomes for the US and the UK was updated and applied to the Australian population.15, 16 The analysis predicted that if smoking prevalence dropped by 5%, over 3,000 hospitalisations for myocardial infarction and 1,000 hospitalisations for stroke would be avoided over only a seven-year period. Health care costs would be reduced by $61.6 million, almost 3% of the total hospitalisation costs for stroke and heart attack over the period.
Another Australian study estimated that in 2008, the potential opportunity cost savings to the health sector were $1,412 million if smoking was eliminated from the population. If the prevalence of smoking was reduced from 23% to 15% (the ideal target), the study estimated a potential opportunity cost savings of $491 million to the health sector.17
Smoking increases the risk of the eye disease, age-related macular degeneration, by 2.5-fold to 4.5-fold. Australian research found that smoking cessation is unequivocally cost-effective in terms of its impact on age-related macular degeneration.18 It predicted that if 1,000 smokers quit, there would be 48 fewer cases of macular degeneration, 12 fewer cases of blindness and the costs of treating and caring for people with macular degeneration would decrease by $2.5 million. If the tobacco control program that facilitated quitting cost less than $1,400 per quitter, it would be cost-saving in terms of its impact on macular degeneration alone.
UK researchers modelled the impacts of achieving a ’tobacco-free’ ambition where, by 2035, less than 5% of the population smoke tobacco across all socioeconomic groups. Due to improved health outcomes, the scenario was predicted to avoid £67 million in direct NHS and social care costs in the year 2035 alone, with most of the savings from fewer cancer cases (£32 million), followed by other diseases.19 US researchers predicted that a 10% relative drop in smoking in every state would be followed by an expected $63 billion reduction (in 2012 US dollars) in healthcare expenditure the next yea20 A study looking at Minnesota estimated that reducing cigarette smoking from 1998 to 2017 has prevented 4,560 cancers, 31,691 hospitalisations for cardiovascular disease and diabetes, 12,881 respiratory disease hospitalisations and 4,118 smoking-attributable deaths. Minnesotans spent an estimated $2.7 billion less in medical care and gained $2.4 billion in paid and unpaid productivity (adjusted to 2017US$).21 Also in the US, researchers estimated the impact of a pregnant woman stopping smoking before the end of the first trimester on pregnancy- and birth-related outcomes. 22 They predicted that a 1% national drop in smoking prevalence would prevent 1,300 low birth weight live births and save $21 million in one year alone (1995 US dollars). A recent study found that increases in cigarette taxes are particularly effective for reducing smoking and improving birth outcomes among the highest-risk women.23
In their reports to state governments in Victoria, Western Australia and New South Wales, Collins and Lapsley have not just quantified the social costs of smoking but have also estimated the social returns that could be expected from future reductions in smoking prevalence.24-26 More recently, consulting firm Creating Preferred Futures estimated the economic benefits of a reduction in the 2015-16 prevalence of smoking in Victoria. Achieving a target of 10 per cent prevalence by 2025 would result in a decline in tangible costs of 14.5 per cent, from $3,696.1 million in 2016 to $3,161.4 million in 2025. Intangible costs associated with loss of life from smoking would decline from $5,777.9 million in 2016 to a low of $4,914.5 million in 2034 – a decline of 14.9 per cent. Reducing smoking prevalence to five per cent would lead to a reduction in tangible costs of 55.6 per cent, from $3,696.1 million in 2016 to $1,639.7 million in 2025. Intangible costs associated with loss of life from smoking would decline from $5,777.9 million in 2016 to a low of $2,457.1 million in 2034 – a decline of 57.5 per cent.27
17.4.2 Economic evaluations of policy interventions
Price-based policy measures (such as increased tobacco taxes) are undoubtedly the most effective strategy for reducing tobacco use and its associated costs. Non-price-based measures (such as smoking restrictions in workplaces, public places, bans on tobacco advertising, and raising the legal age of smokers)—through benefits such as a reduction in smoking prevalence, reduction in second hand smoke, savings from smoking-related medical expenditures, heart diseases averted, costs averted by a reduction in smoking-induced fires, and gains in productivity—have also proven to be both effective and cost saving. A major review found that the cost–effectiveness ratio of implementing non-price-based smoking cessation legislations range from US$2 to US$112 per life year gained, while reducing smoking prevalence by up to 30%–82% in the long term (over a 50-year period).28 Findings in relation to each of these measures are discussed below.
18.104.22.168 Cigarette taxation and price increases
Tobacco tax increases are the single most effective and cost-effective policy to reduce tobacco use and to prevent initiation among young people.29 Such taxes not only reduce demand for tobacco products (see Section 13.1), they cost governments relatively little to implement, and increase government revenues, sometimes substantially.29 An Australian report in 2010 concluded that a 30% tobacco tax would be one of the most cost-effective preventive interventions with the largest population health impact.2 In Brazil, researchers estimated that a 50% increase in cigarette prices would avoid 136,482 deaths, 507,451 cases of cardiovascular diseases, 64,382 cases of cancer, and 100,365 cases of stroke, and the estimated economic benefit would be BRL 97.9 billion (USD 25.5 billion).30 Researchers in China estimates that a 75% increase in cigarette prices would avert about 24 million premature deaths among the current Chinese male population, increase additional tax revenues by US$46 billion annually, and prevent around 9 million cases of poverty.31
A review of modelling studies concluded that interventions that increase the unit price of tobacco products generate substantial healthcare cost savings over the short to medium term and can generate additional gains from improved workplace productivity. Estimates of healthcare cost savings from a 20% price increase ranged from –$0.13 to $86.72 per person per year. After including other benefits such as productivity gains, the total estimated net savings ranged from –$0.13 to $90.98.32 Another major review found that price-based policy measures such as increase in tobacco taxes are the most effective means of reducing tobacco use and in turn the health care costs associated with treating smoking-caused diseases. In all countries where the impact of tax increases have been studied, a 10% tax-induced cigarette price increase reduces smoking prevalence by between 4% and 8%.28
22.214.171.124 Smokefree laws and policies
Smokefree legislation primarily aims to protect non-smokers from the harmful health effects of secondhand smoke. Legislative smoking bans lead to improved health outcomes in the community through reduction in exposure to secondhand smoke, with the clearest evidence for reduced heart attacks and other cardiovascular disease.33-40 Such bans also provides an environment that is conducive to smokers’ efforts to quit.33 Smokefree legislation reduces consumption among continuing smokers,40-42 and may also encourage smokers to quit and to remain abstinent.40 See Section 15.9 for a detailed discussion.
Reductions in both the prevalence of exposure to second-hand smoke and the prevalence of smoking can be expected to lead to a reduction in smoking-related diseases and therefore in health care costs43 An early report issued by the US Environmental Protection Agency analysing the costs and benefits of a proposed national smokefree environment act (requiring that all non-residential buildings regularly entered by 10+ persons in the course of a week prohibit smoking inside the building or restrict it to smoking rooms) estimated the net value to society as between US$39 and US$72 billion.44 Another US study published in 2004 estimated that the total cumulative averted costs over seven years of a national smokefree workplace policy would be nearly $280 million, including $224 million from prevented myocardial infarctions and $55 million from prevented strokes.45
126.96.36.199 Retail promotion and access
Cigarette advertising conveys information about the product’s physical characteristics and ‘personality’. Such advertising is designed primarily to create:
‘fantasies of sophistication, pleasure, social successes, independence or ruggedness. This process can induce individuals who are not smokers to try the product, for those are smokers, to smoke more, for those might have quit, to continue and for those who have quit, to start again.’ (Saffer and Chaloupka,46 Section 2, para 2).
An econometric study prepared for the World Bank compared changes in tobacco consumption in countries that had introduced advertising bans.47 Controlling for price, income and other factors affecting demand, they found that limited bans are minimally effective. Comprehensive bans, however, do reduce tobacco use.
Greater density of tobacco retailers has been suggested as an important factor in the uptake of smoking, and tobacco control advocates have called for limitations to be placed on the number of tobacco retail outlets (see Section 11.9). New Zealand researchers modelled the future health gains and health system cost-savings of tobacco outlet reductions. They found that restricting tobacco sales to only 50% of the country’s liquor stores and no other outlets was the most effective of four interventions, leading to the highest health gains and also to large cost-savings (NZ$1.03 billion). Nonetheless, all four interventions—restricting sales to liquor stores, as well as reducing the total number of outlets by 95%, or eliminating sales from outlets within 1 km or 2km of schools—were cost-saving for the health system.48 Another New Zealand study estimated that proposed ‘endgame’ strategies, including reducing the amount of tobacco imported into the country until commercial supply would end in 2025, introducing a tobacco free generation, or substantially reducing tobacco outlets, would all result in large health gains and cost savings to the health system, especially so for Māori.49
188.8.131.52 Consumer information
In Australia, Applied Economics completed a cost-benefit analysis of new health warnings on cigarette packs prior to their introduction in 2004.50 The new warnings comprised 14 rotating graphic messages covering 50% of the front and back of the cigarette packs Assuming that the new warnings would result in a 3% decrease in smoking rates, the analysts forecast a net benefit of over $2 billion and a benefit:cost ratio greater than 2:1. In the US, researchers attempted to quantify the the national hospital cost savings from the reductions in prenatal smoking that would result from the implementation of graphic warning labels on tobacco packaging. The study concluded that such warnings could lead to hospital cost savings of 1.2 to 2.0 billion dollars over 30 years.51
184.108.40.206 Policies targeting adolescents
In all Australian states and territories, the minimum legal age for purchase of cigarettes is 18 and the distribution of free samples is prohibited.52 The vigour with which such laws are enforced has varied in different jurisdictions over time in Australia.53 Studies suggest that strengthening of laws banning sales to minors in Australia may have contributed to the dramatic declines in youth smoking54, 55 (see Section 5.21).
A cost-effectiveness analysis of programs enforcing the prohibition of tobacco sales to minors has been conducted for the US.56 Reliable data on the effectiveness of such programs was unavailable,57 but the analysts estimated that if enforcement decreases the prevalence of youth smoking by 5%, the cost per life-year saved would range from $440 to $3,100. Enforcement programs are therefore cost-effective, even if their impact on smoking rates is relatively small.
A systematic review published in 2018 found that evidence on the cost-effectiveness of tobacco control policies and programs targeting adolescents, including smoking bans, bans on sales to minors, bans on advertising at points-of-sale, school programs, and media campaigns, is scarce. Nonetheless, all of the included studies concluded that the policies and programs were always cost-effective and, in some cases, ‘dominant’ (that is, cost saving), particularly in studies where the healthcare costs averted were taken into account.58 Another evidence review concluded that school-based smoking prevalence programs could lead to savings of between US$2,000 and US$20,000 per QALY saved due to averted smoking after 2-4 years of follow-up. Such programs tend to reduce short-term smoking prevalence by between 30% and 70%.28 An economic evaluation of five tobacco control policies (bans on sales to minors, bans on smoking in public places, bans on advertising at points-of-sale, school smokefree bans, and school education programs) implemented in 2016 across seven European countries found that all five policies were highly cost effective, even when considering the highest intervention costs and most conservative effectiveness estimates.59
17.4.3 Economic evaluations of population-based strategies
220.127.116.11 Mass media campaigns
Mass media campaigns have consistently been shown to be effective in reducing smoking prevalence and prompting quitting behaviours—see Section 14.4. Mass media campaigns can also be cost-effective. A study of Scotland’s 1992 campaign and an analysis of a four-year media campaign in the US that targeted adolescents both reported costs per life-year saved below $1,000 (2005 US dollars).1, 60, 61
An evaluation of the Australian National Tobacco Campaign (NTC) was initiated by the federal government in 1997.62 The NTC involved intensive television broadcasting of new anti-smoking advertisements and increased funding for support services for smokers attempting to quit. The cost-effectiveness analysis found that the NTC was both cost saving and effective. The campaign cost about $9 million, but predicted health care cost savings exceeded $740 million. About 55,000 deaths were predicted to be prevented and over 400,000 QALYS saved.
The Cancer Council Victoria submitted a report in 2009 to the National Preventative Health Taskforce analysing the potential impact of more intensive tobacco control strategies than the anti-smoking social marketing campaign funded under the National Partnership Agreement on Preventative Health (NPAPH) and scheduled to start that year.63 The report predicted that tobacco taxation increases, combined with additional spending on anti-smoking media, would achieve the Taskforce’s goal of a smoking prevalence of 10% or less by 2020 and would avoid 248,200 premature deaths. Such a program was estimated to cost about $276 million, but would save over $5 billion in health care costs.
An Australian study on the cost effectiveness of online, radio, and print tobacco control advertisements targeting 25–39-year-old males found that online advertising could be more cost effective than other non-television advertising media such as radio and press in reaching and affecting target audiences.64
In 2012, the US CDC launched the first federally funded national mass media antismoking campaign ‘Tips From Former Smokers’, which was found to be highly cost-effective.65 An analysis of the more recent recent ‘Real Cost’ campaign in the US found that the overall return on investment of the campaign was $128 in cost savings for every $1 spent.66 An evaluation of another US campaign designed to prevent smoking initiation among youth and young adults concluded that although public education campaigns require substantial investment, the potential positive impact to society is enormous. A relatively modest number of people taking up smoking need to be averted for such investments to be cost-saving or cost-effective.67
A systematic review published in 2015 concluded that, despite limited evidence, research consistently suggests that tobacco control mass media campaigns offer good value for money; overall, they are able to deliver targeted messages to large populations of people at a low cost per head.68 Another more recent review similarly found that although the included studies were diverse, all showed that mass media campaigns had positive effects on smoking behaviours, and the studies with economic outcomes showed cost effectiveness.69 Another review found that advertising media, telecommunications, and other technology-based interventions (such as TV, radio, print, telephone, the Internet, PC, and other electronic media) usually have positive synergistic effects in reducing smoking prevalence, especially when combined to deliver smoking cessation messages and counselling support. Due to its universal reach and low implementation costs, online campaigns appear to be substantially more cost effective than other media, though may not be as effective in reducing smoking prevalence.28
Telephone quitlines offering counselling and self-help materials operate in all Australian states and territories, and evidence shows that that proactive telephone counselling increases a smoker’s chance of quitting70 (see Section 7.14). An assessment of call-back counselling provided by the quitline in the states of Queensland, Western Australia and the Northern Territory concluded that it both improves health and achieves net cost savings.71 An economic analysis of the Victorian quitline concluded that it is highly cost-effective, improving health and saving costs when added to usual smoking prevention activities. It estimated that provision of the quitline service in 2015 cost $1M and will save the healthcare system approximately $1.2M, 22,202 life years, and 1,480 DALYs over the lifetime of Victorian smokers aged 18 years and over.72
International research has also supported the cost-effectiveness of quitlines. A US study concluded that offering telephone counselling to quitline callers is cost-effective. 73 Callers were randomised to receive mailed self-help booklets or booklets plus telephone counselling. The quit rate 12 months was 4.5% higher in the counselled group and the cost for each additional year of maintained smoking cessation was $1,300 (US dollars, 2000). Another US study74 as well as research in Spain75 found that proactive telephone outreach was effective and cost-effective. A Swedish study assessed the 12-month quit rate for over 1,000 callers to the national quitline.76 Over 30% of callers quit and the cost per life-year saved was estimated at between $311 and $401 (US dollars, 2002). An evaluation of the quitline in Thailand also found it to be a cost-effective intervention,77 and New Zealand researchers estimated that an intervention package of a quitline service and its mass media promotion would generate substantial health gain and would be cost saving for the health system.78 Several studies have concluded that providing NRT through Quitlines increases cost-effectiveness.79-82
Internet and mobile phone-based interventions for smoking cessation can also be effective (see Section 7.14), and the high reach and low cost of such interventions could greatly increase the cost-effectiveness of smoking cessation services. Several studies have shown that internet-83-86 and mobile phone-based87, 88 cessation interventions increase abstinence and are cost-effective.
17.4.4 Economic evaluations of clinical interventions
The main clinical tobacco control interventions are behavioural support to stop smoking and pharmacotherapies. Behavioural support can be brief (such as advice from a health professional) or more intensive, involving repeated counselling sessions. Both behavioural support and use of pharmacotherapies increase a person’s likelihood of successfully quitting, with optimal treatment comprising a combination of both—see Chapter 7. The use of pharmacotherapies such as varenicline, NRT, and bupropion, when combined with GP counselling or other behavioural treatment interventions (such as proactive telephone counselling and web-based delivery), is both clinically effective and cost effective to primary health care providers.28 Because both pharmaco- and behavioural therapies for smoking cessation are cost-effective or even cost-saving, smoking cessation programs are regarded as the gold standard of cost-effectiveness in health care.89
18.104.22.168 Healthcare system interventions
Along with the use of pharmacological and behavioural treatments, research clearly demonstrates the effectiveness and cost-effectiveness of promotion of cessation by health care professionals, and integration of cessation treatments into healthcare systems.90 Because brief advice to quit smoking is effective91 and inexpensive, and because the health and economic benefits of quitting are large, smoking cessation advice has long been recognised as very cost-effective intervention. For example, a review found that five minute physician or nurse smoking cessation counselling had cost-effectiveness ratios less than $5000 per life-year saved.92 Smoking cessation advice was more cost-effective than most of the other prevention strategies considered.
Reviews have concluded that smoking cessation advice and assistance to quit smoking is one of the most cost-effective disease prevention services available in clinical settings. In the US, an evaluation of clinical preventive services concluded that providing smoking cessation advice and help to quit was one of only three services that received the highest ranking for both health impact and economic value.93 The other services were childhood immunisation and daily aspirin use for prevention of cardiovascular disease. Research from Ontario concluded that a best practice smoking cessation program for cancer patients (screening, advice, and referral plus pharmacological therapy) has the potential to be cost-effective option when compared to a basic smoking cessation program (screening, advice, and referral).94 Studies have also supported the cost-effectiveness of preoperative smoking cessation interventions,95, 96 hospital inpatient tobacco dependence treatment,97-99 proactive tobacco treatment outreach strategies,100 and funding smoking cessation programs for Crohn's disease101 and COPD.102 A recent review concluded that community pharmacist-based smoking cessation programs yield cost savings to the health system of between US$500 and US$614 per life year gained.28
Smoking cessation guidelines for doctors recommend that smokers who wish to quit be offered pharmacotherapy.103 In Australia, three pharmacotherapies are available: nicotine replacement therapy (NRT), bupropion and varenicline—see Section 7.16. The Pharmaceutical Benefits Advisory Committee (PBAC) recommends to the Minister for Health which drugs should be subsidised under the Pharmaceutical Benefits Scheme. A medicine must be effective and cost-effective in order to be subsidised.104, 105 The three available smoking cessation pharmacotherapies have each been recommended for subsidy by the PBAC; they are all regarded as ‘cost-effective’. The Australian project, Assessing Cost-effectiveness in Prevention (ACE–Prevention), found that the three smoking cessation pharmacotherapies were ‘very cost-effective preventive interventions’. All three medicines had cost-effectiveness ratios of $10,000 per DALY saved or less.2 A major evidence review concluded that the cost per life year saved from the use of pharmacological treatment interventions ranged between US$128 and US$1,450 and up to US$4,400 per quality-adjusted life years (QALYs) saved.28
International research has found that varenicline is cost-effective compared with other smoking cessation interventions such as bupropion and NRT.106-111 However, these comparative cost-effectiveness findings are dependent on the cost of a course of each therapy and the analysts’ assumptions about relative effectiveness. Three Australian studies considered prior to listing of NRT on Australia’s Pharmaceutical Benefits Scheme (PBS) analysed the relative cost-effectiveness of these smoking cessation pharmacotherapies.112-114 Two studies at that time found bupropion more cost-effective than NRT,112, 114 and one study found varenicline more cost-effective than both NRT and bupropion.113 The Pharmaceutical Benefits Advisory Committee regards nicotine patch as safer and cheaper than bupropion and views the two drugs as having comparable efficacy. The PBAC considers varenicline as superior in effectiveness to bupropion, NRT and placebo, and comparable in safety.115, 116 Several additional studies have similarly confirmed that varenicline is more effective than bupropion and NRT for smoking cessation.117, 118 However, NRT is considerably cheaper, hence the decision to include it on Australia’s PBS.
Several US studies have concluded that expansion of coverage for smoking cessation prescriptions with no out-of-pocket costs could reduce healthcare expenditures, based on thousands of extra quitters and hundreds of thousands in healthcare savings.119-121 Research in the Netherlands and the UK examined the cost-effectiveness of extending current cessation practices to include: increasing the reach of top‐level services to increase potential quitters (e.g. brief physician advice); increasing the reach of behavioural support to increase the success rates; (c) including a new but effective medication (cytisine); and (d) all changes implemented together (combined change). It found that 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.122 Studies in Spain75 and France123 also support the cost-effectiveness of reimbursing smoking cessation medications. Japanese researchers predicted that an increased use of smoking cessation pharmacotherapy to support quit attempts would increase the number of smokers achieving abstinence and would be beneficial both due to a reduction in healthcare costs and increased productivity.124
22.214.171.124 Workplace interventions
Workplace smoking interventions can include pharmacological interventions, behavioural interventions, or a combination of both, and generally include strategies such as smoking bans, incentives, competitions, individual and group counselling, self-help materials, pharmacotherapy, and social and environmental support. A recent review found that such interventions can be cost-effective, achieving a benefit-cost ratio of up to 8.75 and generating 12-month employer cost savings of between $150 and $540 per nonsmoking employee. Implementing smokefree workplaces can also promote quitting and reduce consumption, leading to lower healthcare costs. Workplace interventions are, however, likely to yield far greater economic benefits over the long term, as reduced prevalence will lead to a healthier and more productive workforce.28 A recent modelling study estimated the budget impact of funding pharmaco- and behavioural therapies for smoking cessation from an employer perspective and concluded that, considering the avoided costs of loss of productivity and absenteeism, funding such a program would produce substantial savings for the employer.125
Relevant news and research
For recent news items and research on this topic, click here ( Last updated January 2021)
1. Kahende JW, Loomis BR, Adhikari B, and Marshall L. A review of economic evaluations of tobacco control programs. International Journal of Environmental Research and Public Health, 2009; 6(1):51-68. Available from: https://www.ncbi.nlm.nih.gov/pubmed/19440269
2. Vos T, Carter R, Barendregt J, Mihalopoulos C, Veerman L, et al. Assessing cost-effectiveness in prevention (ace–prevention) final report. Melbourne: Victorian Health Promotion Foundation, 2010. Available from: http://www.vichealth.vic.gov.au/~/media/About%20Us/Health%20promotion/ACE-Prevention_Sept2010_FINAL.ashx.
3. Rogers T. The California tobacco control program: Introduction to the 20-year retrospective. Tobacco Control, 2010; 19 Suppl 1(Suppl 1):i1-2. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20382644
4. Roeseler A and Burns D. The quarter that changed the world. Tobacco Control, 2010; 19(Supplement 1):i3-i15. Available from: http://tobaccocontrol.bmj.com/content/19/Suppl_1/i3.abstract
5. Zhang X, Cowling DW, and Tang H. The impact of social norm change strategies on smokers' quitting behaviours. Tobacco Control, 2010; 19 Suppl 1(Suppl 1):i51-5. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20382651
6. Miller LS, Max W, Sung HY, Rice D, and Zaretsky M. Evaluation of the economic impact of california's tobacco control program: A dynamic model approach. Tobacco Control, 2010; 19 Suppl 1(Suppl 1):i68-76. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20382654
7. Applied Economics. Returns on investment in public health: An epidemiological and economic analysis Department of Health and Ageing, 2003. Available from: http://www.appliedeconomics.com.au/pubs/reports/health/index.htm#TopOfPage.
8. Farrelly M, Pechacek TF, and Chaloupka F. The impact of tobacco control program expenditures on aggregate cigarette sales: 1981-1998. Journal of Health Economics, 2003.
9. Tauras JA, Chaloupka FJ, Farrelly MC, Giovino GA, Wakefield M, et al. State tobacco control spending and youth smoking. American Journal of Public Health, 2005; 95(2):338-44. Available from: https://www.ncbi.nlm.nih.gov/pubmed/15671473
10. Polednak AP. Trends in death rates from tobacco-related cardiovascular diseases in selected US states differing in tobacco-control efforts. Epidemiology, 2009; 20(4):542-6. Available from: https://www.ncbi.nlm.nih.gov/pubmed/19367166
11. Lightwood JM, Dinno A, and Glantz SA. Effect of the California tobacco control program on personal health care expenditures. PLoS Medicine, 2008; 5(8):e178. Available from: https://www.ncbi.nlm.nih.gov/pubmed/18752344
12. Hurley SF, Scollo MM, Younie SJ, English DR, and Swanson MG. The potential for tobacco control to reduce pbs costs for smoking-related cardiovascular disease. Medical Journal of Australia, 2004; 181(5):252-5. Available from: https://www.ncbi.nlm.nih.gov/pubmed/15347272
13. Costello P. 2002–03 budget paper no. 5. Intergenerational report 2002–03. Canberra: Commonwealth of Australia, 2002. Available from: https://treasury.gov.au/sites/default/files/2019-03/2002-IGR-report.pdf.
14. Hurley SF. Short-term impact of smoking cessation on myocardial infarction and stroke hospitalisations and costs in Australia. Medical Journal of Australia, 2005; 183(1):13-7. Available from: https://www.ncbi.nlm.nih.gov/pubmed/15992331
15. Lightwood JM and Glantz SA. Short-term economic and health benefits of smoking cessation: Myocardial infarction and stroke. Circulation, 1997; 96(4):1089-96. Available from: https://www.ncbi.nlm.nih.gov/pubmed/9286934
16. Naidoo B, Stevens W, and McPherson K. Modelling the short term consequences of smoking cessation in England on the hospitalisation rates for acute myocardial infarction and stroke. Tobacco Control, 2000; 9(4):397-400. Available from: https://www.ncbi.nlm.nih.gov/pubmed/11106709
17. Cadilhac D, Cumming T, Sheppard L, Pearce D, and Carter R. The health and economic benefits of reducing disease risk factors. Melbourne 2009. Available from: https://www.vichealth.vic.gov.au/media-and-resources/publications/health-and-economic-benefits-of-reducing-disease-risk-factors.
18. Hurley SF, Matthews JP, and Guymer RH. Cost-effectiveness of smoking cessation to prevent age-related macular degeneration. Cost Eff Resour Alloc, 2008; 6(1):18. Available from: https://www.ncbi.nlm.nih.gov/pubmed/18783631
19. Hunt D, Knuchel-Takano A, Jaccard A, Bhimjiyani A, Retat L, et al. Modelling the implications of reducing smoking prevalence: The public health and economic benefits of achieving a ‘tobacco-free’ UK. Tobacco Control, 2017; 27(2):129–35. Available from: http://tobaccocontrol.bmj.com/content/tobaccocontrol/27/2/129.full.pdf
20. Lightwood J and Glantz SA. Smoking behavior and healthcare expenditure in the United States, 1992-2009: Panel data estimates. PLoS Medicine, 2016; 13(5):e1002020. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27163933
21. Maciosek MV, LaFrance AB, St Claire A, Xu Z, Brown M, et al. Twenty-year health and economic impact of reducing cigarette use: Minnesota 1998-2017. Tobacco Control, 2019. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31413150
22. Lightwood JM, Phibbs CS, and Glantz SA. Short-term health and economic benefits of smoking cessation: Low birth weight. Pediatrics, 1999; 104(6):1312-20. Available from: https://www.ncbi.nlm.nih.gov/pubmed/10585982
23. Hawkins SS, Baum CF, Oken E, and Gillman MW. Associations of tobacco control policies with birth outcomes. JAMA Pediatr, 2014; 168(11):e142365. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25365250
24. Collins D and Lapsley H. Counting the costs of tobacco and the benefits of reducing smoking prevalence in Western Australia. Monograph series, no 4. Perth: The Cancer Council Western Australia, 2004.
25. Collins D and Lapsley H. Counting the costs of tobacco and the benefits of reducing smoking prevalence in New South Wales. Sydney: New South Wales Department of Health, 2005.
26. Collins D and Lapsley H. Counting the costs of tobacco and the benefits of reducing smoking prevalence in Victoria. Victorian Department of Human Services, 2006. Available from: https://www2.health.vic.gov.au/about/publications/Factsheets/Counting%20the%20costs%20of%20tobacco%20and%20the%20benefits%20of%20reducing%20smoking%20prevalence%20in%20Victoria.
27. Creating Preferred Futures. The economic benefits of a reduction in the 2015-16 prevalence of smoking in Victoria. Hobart, Tasmania 2018.
28. Ekpu VU and Brown AK. The economic impact of smoking and of reducing smoking prevalence: Review of evidence. Tob Use Insights, 2015; 8:1-35. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26242225
29. World Health Organization. Who report on the global tobacco epidemic: Raising taxes on tobacco. Geneva: WHO, 2015. Available from: http://www.who.int/tobacco/global_report/2015/en/index.html.
30. Pinto M, Bardach A, Palacios A, Biz A, Alcaraz A, et al. Burden of smoking in Brazil and potential benefit of increasing taxes on cigarettes for the economy and for reducing morbidity and mortality. Cadernos de Saude Publica, 2019; 35(8):e00129118. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31483047
31. Verguet S, Tarr G, Gauvreau CL, Mishra S, Jha P, et al. Distributional benefits of tobacco tax and smoke-free workplaces in china: A modeling study. J Glob Health, 2017; 7(2):020701. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29188029
32. Contreary KA, Chattopadhyay SK, Hopkins DP, Chaloupka FJ, Forster JL, et al. Economic impact of tobacco price increases through taxation: A community guide systematic review. American Journal of Preventive Medicine, 2015; 49(5):800-8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26188686
33. Frazer K, Callinan JE, McHugh J, van Baarsel S, Clarke A, et al. Legislative smoking bans for reducing harms from secondhand smoke exposure, smoking prevalence and tobacco consumption. Cochrane Database of Systematic Reviews, 2016; 2:CD005992. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26842828
34. Jones MR, Barnoya J, Stranges S, Losonczy L, and Navas-Acien A. Cardiovascular events following smoke-free legislations: An updated systematic review and meta-analysis. Curr Environ Health Rep, 2014; 1(3):239-49. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25328861
35. Abe TMO, Scholz J, de Masi E, Nobre MRC, and Filho RK. Decrease in mortality rate and hospital admissions for acute myocardial infarction after the enactment of the smoking ban law in sao paulo city, Brazil. Tobacco Control, 2017; 26(6):656-62. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27794066
36. Abreu D, Sousa P, Matias-Dias C, and Pinto FJ. Longitudinal impact of the smoking ban legislation in acute coronary syndrome admissions. Biomed Res Int, 2017; 2017:6956941. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28265574
37. Nazzal C and Harris JE. Lower incidence of myocardial infarction after smoke-free legislation enforcement in chile. Bulletin of the World Health Organization, 2017; 95(10):674-82. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29151635
38. Yang YN, Huang YT, and Yang CY. Effects of a national smoking ban on hospital admissions for cardiovascular diseases: A time-series analysis in taiwan. Journal of Toxicology and Environmental Health. Part A, 2017; 80(10-12):562-8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28880815
39. Lin H, Wang H, Wu W, Lang L, Wang Q, et al. The effects of smoke-free legislation on acute myocardial infarction: A systematic review and meta-analysis. BMC Public Health, 2013; 13:529. Available from: https://www.ncbi.nlm.nih.gov/pubmed/23721370
40. International Agency for Research on Cancer. Evaluating the effectiveness of smoke-free policies. Handbooks of cancer prevention, tobacco control, vol. 13.Lyon, France: IARC, 2009. Available from: https://www.iarc.fr/wp-content/uploads/2018/07/handbook13.pdf.
41. Chapman S, Borland R, Scollo M, Brownson RC, Dominello A, et al. The impact of smoke-free workplaces on declining cigarette consumption in Australia and the United States. American Journal of Public Health, 1999; 89(7):1018–23. Available from: https://www.ncbi.nlm.nih.gov/pubmed/10394309
42. Fichtenberg C and Glantz S. Effect of smokefree workplaces on smoking behaviour: Systematic review. BMJ (Clinical Research Ed.), 2002; 325(7357):188. Available from: http://www.bmj.com/cgi/content/full/325/7357/188?view=long&pmid=12142305
43. IARC Handbooks of Cancer Prevention Tobacco Control. Chapter 4. Impact of smoke-free policies on businesses, the hospitality sector, and other incidental outcomes, in Evaluating the effectiveness of smoke-free policies. Lyon, France: International Agency for Research on Cancer; 2009. Available from: http://publications.iarc.fr/383.
44. Mudarri D. The costs and benefits of smoking restrictions: An assessment of the smoke-free environment act of 1993 (h.R. 3434). Washington, DC: United States Environmental Protection Agency, Office of Radiation and Indoor Air, 1994.
45. Ong MK and Glantz SA. Cardiovascular health and economic effects of smoke-free workplaces. American Journal of Medicine, 2004; 117(1):32-8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/15210386
46. Saffer H and Chaloupka F, Tobacco advertising: Economic theory and international evidence working paper 6958. Cambridge: National Bureau of Economic Research; 1999.
47. Saffer H and Chaloupka F. The effect of tobacco advertising bans on tobacco consumption. Journal of Health Economics, 2000; 19(6):1117-37. Available from: https://www.ncbi.nlm.nih.gov/pubmed/11186847
48. Pearson AL, Cleghorn CL, van der Deen FS, Cobiac LJ, Kvizhinadze G, et al. Tobacco retail outlet restrictions: Health and cost impacts from multistate life-table modelling in a national population. Tobacco Control, 2017; 26(5):579-85. Available from: http://tobaccocontrol.bmj.com/content/tobaccocontrol/26/5/579.full.pdf
49. van der Deen FS, Wilson N, Cleghorn CL, Kvizhinadze G, Cobiac LJ, et al. Impact of five tobacco endgame strategies on future smoking prevalence, population health and health system costs: Two modelling studies to inform the tobacco endgame. Tobacco Control, 2018; 27(3):278-86. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28647728
50. Applied Economics. Cost-benefit analysis of proposed new health warning on tobacco products. Commonwealth Department of Health and Ageing, 2003.
51. Tauras JA, Peck RM, Cheng KW, and Chaloupka FJ. Graphic warning labels and the cost savings from reduced smoking among pregnant women. International Journal of Environmental Research and Public Health, 2017; 14(2). Available from: https://www.ncbi.nlm.nih.gov/pubmed/28208749
52. Winstanley M and Wood L. Chapter 5. Factors influencing the uptake and prevention of smoking, in Tobacco in Australia: Facts and issues. Scollo M, and Winstanley, M, Editor Melbourne: Quit Victoria; 2008. Available from: https://www.tobaccoinaustralia.org.au/chapter-5-uptake.
53. Purcell K. A national approach for reducing access to tobacco in Australia by young people under 18 years of age. Canberra: Commonwealth of Australia, 2000. Available from: https://www1.health.gov.au/internet/main/publishing.nsf/Content/20DEAAFCDB122BFCCA257BF000217A6B/$File/minors.pdf.
54. Tutt D, Bauer L, and DiFranza J. Restricting the retail supply of tobacco to minors. Journal of Public Health Policy, 2009; 30(1):68–82. Available from: http://www.palgrave-journals.com/jphp/journal/v30/n1/full/jphp200844a.html
55. White V and Warne C. Michelle will add details later. In submission.
56. DiFranza JR, Peck RM, Radecki TE, and Savageau JA. What is the potential cost-effectiveness of enforcing a prohibition on the sale of tobacco to minors? Preventive Medicine, 2001; 32(2):168-74. Available from: https://www.ncbi.nlm.nih.gov/pubmed/11162343
57. Stead LF and Lancaster T Interventions for preventing tobacco sales to minors. Cochrane Database of Systematic Reviews, 2005 DOI: 10.1002/14651858.CD001497.pub2. Available from: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001497.pub2/full
58. Leao T, Kunst AE, and Perelman J. Cost-effectiveness of tobacco control policies and programmes targeting adolescents: A systematic review. European Journal of Public Health, 2018; 28(1):39-43. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29267928
59. Leao T, Perelman J, Clancy L, Mlinaric M, Kinnunen JM, et al. Economic evaluation of five tobacco control policies across seven European countries. Nicotine and Tobacco Research, 2019. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31350556
60. Secker-Walker RH, Worden JK, Holland RR, Flynn BS, and Detsky AS. A mass media programme to prevent smoking among adolescents: Costs and cost effectiveness. Tobacco Control, 1997; 6(3):207–12. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1759579/
61. Ratcliffe J, Cairns J, and Platt S. Cost effectiveness of a mass media-led anti-smoking campaign in Scotland. Tobacco Control, 1997; 6(2):104-10. Available from: https://www.ncbi.nlm.nih.gov/pubmed/9291218
62. Hurley SF and Matthews JP. Cost-effectiveness of the Australian national tobacco campaign. Tobacco Control, 2008; 17(6):379-84. Available from: https://www.ncbi.nlm.nih.gov/pubmed/18719075
63. VicHealth Centre for Tobacco Control. Predicted impact of proposed tobacco control strategies. Melbourne: Cancer Council Victiria, 2009.
64. Clayforth C, Pettigrew S, Mooney K, Lansdorp-Vogelaar I, Rosenberg M, et al. A cost-effectiveness analysis of online, radio and print tobacco control advertisements targeting 25-39 year-old males. Australian and New Zealand Journal of Public Health, 2014; 38(3):270-4. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24750454
65. Xu X, Alexander RL, Jr., Simpson SA, Goates S, Nonnemaker JM, et al. A cost-effectiveness analysis of the first federally funded antismoking campaign. American Journal of Preventive Medicine, 2015; 48(3):318-25. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25498550
66. MacMonegle AJ, Nonnemaker J, Duke JC, Farrelly MC, Zhao X, et al. Cost-effectiveness analysis of the real cost campaign's effect on smoking prevention. American Journal of Preventive Medicine, 2018; 55(3):319-25. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30122214
67. Weir BW, Cantrell J, Holtgrave DR, Greenberg MS, Kennedy RD, et al. Cost and threshold analysis of the finishit campaign to prevent youth smoking in the United States. International Journal of Environmental Research and Public Health, 2018; 15(8). Available from: https://www.ncbi.nlm.nih.gov/pubmed/30082612
68. Atusingwize E, Lewis S, and Langley T. Economic evaluations of tobacco control mass media campaigns: A systematic review. Tobacco Control, 2015; 24(4):320-7. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24985730
69. Feirman SP, Glasser AM, Rose S, Niaura R, Abrams DB, et al. Computational models used to assess US tobacco control policies. Nicotine and Tobacco Research, 2017; 19(11):1257-67. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28339561
70. Matkin W, Ordonez-Mena JM, and Hartmann-Boyce J. Telephone counselling for smoking cessation. Cochrane Database of Systematic Reviews, 2019; 5(5):CD002850. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31045250
71. Lal A, Mihalopoulos C, Wallace A, and Vos T. The cost-effectiveness of call-back counselling for smoking cessation. Tobacco Control, 2014; 23(5):437-42. Available from: https://www.ncbi.nlm.nih.gov/pubmed/23748188
72. McCaffrey N and Carter R. Economic evaluation of the Victorian quitline service. Melbourne: Deakin University and Cancer Council Victoria, 2018. Available from: https://www.quit.org.au/documents/245/Economic_evaluation_of_the_Victorian_Quitline_service.pdf.
73. McAlister AL, Rabius V, Geiger A, Glynn TJ, Huang P, et al. Telephone assistance for smoking cessation: One year cost effectiveness estimations. Tobacco Control, 2004; 13(1):85-6. Available from: https://www.ncbi.nlm.nih.gov/pubmed/14985603
74. Thao V, Nyman JA, Nelson DB, Joseph AM, Clothier B, et al. Cost-effectiveness of population-level proactive tobacco cessation outreach among socio-economically disadvantaged smokers: Evaluation of a randomized control trial. Addiction, 2019; 114(12):2206-16. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31483549
75. Trapero-Bertran M, Munoz C, Coyle K, Coyle D, Lester-George A, et al. Cost-effectiveness of alternative smoking cessation scenarios in spain: Results from the equiptmod. Addiction, 2018; 113 Suppl 1:65-75. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29532966
76. Tomson T, Helgason AR, and Gilljam H. Quitline in smoking cessation: A cost-effectiveness analysis. International Journal of Technology Assessment in Health Care, 2004; 20(4):469–74. Available from: https://www.ncbi.nlm.nih.gov/pubmed/15609797
77. Meeyai A, Yunibhand J, Punkrajang P, and Pitayarangsarit S. An evaluation of usage patterns, effectiveness and cost of the national smoking cessation quitline in Thailand. Tobacco Control, 2015; 24(5):481-8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24920575
78. Nghiem N, Cleghorn CL, Leung W, Nair N, Deen FSV, et al. A national quitline service and its promotion in the mass media: Modelling the health gain, health equity and cost-utility. Tobacco Control, 2018; 27(4):434-41. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28739609
79. Cummings KM, Hyland A, Fix B, Bauer U, Celestino P, et al. Free nicotine patch giveaway program 12-month follow-up of participants. American Journal of Preventive Medicine, 2006; 31(2):181-4. Available from: https://www.ncbi.nlm.nih.gov/pubmed/16829336
80. Fellows JL, Bush T, McAfee T, and Dickerson J. Cost effectiveness of the oregon quitline "free patch initiative". Tobacco Control, 2007; 16(Suppl_1):i47-52. Available from: http://tobaccocontrol.bmj.com/cgi/content/abstract/16/Suppl_1/i47
81. Hollis JF, McAfee TA, Fellows JL, Zbikowski SM, Stark M, et al. The effectiveness and cost effectiveness of telephone counselling and the nicotine patch in a state tobacco quitline. Tobacco Control, 2007; 16(Suppl 1):i53−9. Available from: http://tobaccocontrol.bmj.com/cgi/content/abstract/16/Suppl_1/i53
82. Sung HY, Penko J, Cummins SE, Max W, Zhu SH, et al. Economic impact of financial incentives and mailing nicotine patches to help medicaid smokers quit smoking: A cost-benefit analysis. American Journal of Preventive Medicine, 2018; 55(6 Suppl 2):S148-S58. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30454669
83. Stanczyk NE, Smit ES, Schulz DN, de Vries H, Bolman C, et al. An economic evaluation of a video- and text-based computer-tailored intervention for smoking cessation: A cost-effectiveness and cost-utility analysis of a randomized controlled trial. PLoS ONE, 2014; 9(10):e110117. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25310007
84. Smit ES, Evers SM, de Vries H, and Hoving C. Cost-effectiveness and cost-utility of internet-based computer tailoring for smoking cessation. Journal of Medical Internet Research, 2013; 15(3):e57. Available from: https://www.ncbi.nlm.nih.gov/pubmed/23491820
85. Wu Q, Parrott S, Godfrey C, Gilbert H, Nazareth I, et al. Cost-effectiveness of computer-tailored smoking cessation advice in primary care: A randomized trial (escape). Nicotine and Tobacco Research, 2014; 16(3):270-8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24084467
86. Cheung KL, Wijnen BFM, Hiligsmann M, Coyle K, Coyle D, et al. Is it cost-effective to provide internet-based interventions to complement the current provision of smoking cessation services in the netherlands? An analysis based on the equiptmod. Addiction, 2018; 113 Suppl 1:87-95. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29243351
87. Ramirez AG, Chalela P, Akopian D, Munoz E, Gallion KJ, et al. Text and mobile media smoking cessation service for young adults in south texas: Operation and cost-effectiveness estimation. Health Promotion Practice, 2017; 18(4):581-5. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28438055
88. Daly AT, Deshmukh AA, Vidrine DJ, Prokhorov AV, Frank SG, et al. Cost-effectiveness analysis of smoking cessation interventions using cell phones in a low-income population. Tobacco Control, 2019; 28(1):88-94. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29886411
89. Ruger JP and Lazar CM. Economic evaluation of pharmaco- and behavioral therapies for smoking cessation: A critical and systematic review of empirical research. Annual Review of Public Health, 2012; 33:279-305. Available from: https://www.ncbi.nlm.nih.gov/pubmed/22224889
90. U.S. National Cancer Institute and World Health Organization. Chapter 9: Smoking cessation, in National Cancer Institute Tobacco Control Monograph 21.The Economics of Tobacco and Tobacco Control. Section 4—Non-Price Determinants of Demand. NIH Publication, Bethesda, MD: U.S. Department of Health and Human Services, National Institutes of Health, National Cancer Institute; and Geneva, CH: World Health Organization: 2016. Available from: https://cancercontrol.cancer.gov/brp/tcrb/monographs/21/docs/m21_9.pdf.
91. Stead LF, Buitrago D, Preciado N, Sanchez G, Hartmann-Boyce J, et al. Physician advice for smoking cessation. Cochrane Database of Systematic Reviews, 2013 DOI: 10.1002/14651858.CD000165.pub4. Available from: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD000165.pub4/full
92. Brown AD and Garber AM. Cost effectiveness of coronary heart disease prevention strategies in adults. Pharmacoeconomics, 1998; 14(1):27-48. Available from: https://www.ncbi.nlm.nih.gov/pubmed/10182193
93. Maciosek MV, Coffield AB, Edwards NM, Flottemesch TJ, and Solberg LI. Prioritizing clinical preventive services: A review and framework with implications for community preventive services. Annual Review of Public Health, 2009; 30(1):341-55. Available from: https://www.ncbi.nlm.nih.gov/pubmed/19705561
94. Djalalov S, Masucci L, Isaranuwatchai W, Evans W, Peter A, et al. Economic evaluation of smoking cessation in ontario's regional cancer programs. Cancer Med, 2018; 7(9):4765-72. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30019421
95. Boylan MR, Bosco JA, 3rd, and Slover JD. Cost-effectiveness of preoperative smoking cessation interventions in total joint arthroplasty. Journal of Arthroplasty, 2019; 34(2):215-20. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30482665
96. Kulaylat AS, Hollenbeak CS, and Soybel DI. Cost-utility analysis of smoking cessation to prevent operative complications following elective abdominal colon surgery. American Journal of Surgery, 2018; 216(6):1082-9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30262122
97. Cartmell KB, Dismuke CE, Dooley M, Mueller M, Nahhas GJ, et al. Effect of an evidence-based inpatient tobacco dependence treatment service on 1-year postdischarge health care costs. Medical Care, 2018; 56(10):883-9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30130271
98. Lee D, Lee YR, and Oh IH. Cost-effectiveness of smoking cessation programs for hospitalized patients: A systematic review. European Journal of Health Economics, 2019; 20(9):1409-24. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31452084
99. Mullen KA, Coyle D, Manuel D, Nguyen HV, Pham B, et al. Economic evaluation of a hospital-initiated intervention for smokers with chronic disease, in ontario, Canada. Tobacco Control, 2015; 24(5):489-96. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24935442
100. Levy DE, Klinger EV, Linder JA, Fleegler EW, Rigotti NA, et al. Cost-effectiveness of a health system-based smoking cessation program. Nicotine and Tobacco Research, 2017; 19(12):1508-15. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27639095
101. Coward S, Heitman SJ, Clement F, Negron M, Panaccione R, et al. Funding a smoking cessation program for crohn's disease: An economic evaluation. American Journal of Gastroenterology, 2015; 110(3):368-77. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25350768
102. Jimenez-Ruiz CA, Solano-Reina S, Signes-Costa J, de Higes-Martinez E, Granda-Orive JI, et al. Budgetary impact analysis on funding smoking-cessation drugs in patients with COPD in spain. International Journal of Chronic Obstructive Pulmonary Disease, 2015; 10:2027-36. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26451100
103. Zwar N, Richmond R, Borland R, Stillman S, Cunningham M, et al. Smoking cessation guidelines for Australian general practice. Practice handbook 2004 edition. Canberra: Royal Australian College of General Practitioners, 2004. Available from: https://www.who.int/fctc/reporting/Australia_annex8_smoking_cessation_guidelines.pdf.
104. Pharmaceutical Benefits Advisory C. Guidelines for preparing submissions to the pharmaceutical benefits advisory committee (version 4.2). December 2007: Checklists and tables. Department of Health and Ageing, Commonwealth of Australia, 2007.
105. George B, Harris A, and Mitchell A. Cost-effectiveness analysis and the consistency of decision making: Evidence from pharmaceutical reimbursement in australia (1991 to 1996). Pharmacoeconomics, 2001; 19(11):1103-9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/11735677
106. Baker CL and Pietri G. A cost-effectiveness analysis of varenicline for smoking cessation using data from the eagles trial. Clinicoecon Outcomes Res, 2018; 10:67-74. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29403297
107. Lee LJ, Li Q, Bruno M, Emir B, Murphy B, et al. Healthcare costs of smokers using varenicline versus nicotine-replacement therapy patch in the United States: Evidence from real-world practice. Advances in Therapy, 2019; 36(2):365-80. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30569324
108. von Wartburg M, Raymond V, and Paradis PE. The long-term cost-effectiveness of varenicline (12-week standard course and 12 + 12-week extended course) vs. Other smoking cessation strategies in Canada. International Journal of Clinical Practice, 2014; 68(5):639-46. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24472120
109. Annemans L, Nackaerts K, Bartsch P, Prignot J, and Marbaix S. Cost effectiveness of varenicline in belgium, compared with bupropion, nicotine replacement therapy, brief counselling and unaided smoking cessation: A benesco markov cost-effectiveness analysis. Clinical Drug Investigation, 2009; 29(10):655-65. Available from: https://www.ncbi.nlm.nih.gov/pubmed/19715382
110. Bae JY, Kim CH, and Lee EK. Evaluation of cost-utility of varenicline compared with existing smoking cessation therapies in South Korea. Value in Health, 2009; 12 Suppl 3:S70-3. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20586986
111. Howard P, Knight C, Bolar A, and Baker C. Cost-utility analysis of varenicline versus existing smoking cessation strategies using the benesco simulation model: Application to a population of US adult smokers. Pharmacoeconomics, 2008; 26(6):497–511. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18489200
112. Bertram MY, Lim SS, Wallace AL, and Vos T. Costs and benefits of smoking cessation aids: Making a case for public reimbursement of nicotine replacement therapy in Australia. Tobacco Control, 2007; 16(4):255-60. Available from: https://www.ncbi.nlm.nih.gov/pubmed/17652241
113. Perez DCT, Makino K, Bhatti T, Gordois A, Guarnieri C, et al. Pharmacotherapy evaluation. Drugs that assist smoking cessation. October 2008. Cancer Institute NSW Catalogue number: PM-2008-5 NSW: Cancer Institute NSW, 2008.
114. Shearer J and Shanahan M. Cost effectiveness analysis of smoking cessation interventions. Australian and New Zealand Journal of Public Health, 2006; 30(5):428-34. Available from: https://www.ncbi.nlm.nih.gov/pubmed/17073223
115. Pharmaceutical Benefits Advisory Committee. November 2016 pbac meeting - pbs. 2016. Available from: https://www.pbs.gov.au/industry/listing/elements/pbac-meetings/psd/2016-11/files/varenicline-psd-november-2016.docx
116. Australian Government Department of Health and Ageing. March 2010 pbac meeting outcomes - positive recommendations. 2010. Available from: http://www.pbs.gov.au/pbs/industry/listing/elements/pbac-meetings/pbac-outcomes/2010-03/positive-recommendations.
117. Anthenelli RM, Benowitz NL, West R, St Aubin L, McRae T, et al. Neuropsychiatric safety and efficacy of varenicline, bupropion, and nicotine patch in smokers with and without psychiatric disorders (eagles): A double-blind, randomised, placebo-controlled clinical trial. Lancet, 2016; 387(10037):2507-20. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27116918
118. Cahill K, Lindson-Hawley N, Thomas KH, Fanshawe TR, and Lancaster T. Nicotine receptor partial agonists for smoking cessation. Cochrane Database of Systematic Reviews, 2016; 5(5):CD006103. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27158893
119. Athar H, Chen ZA, Contreary K, Xu X, Dube SR, et al. Impact of increasing coverage for select smoking cessation therapies with no out-of-pocket cost among the medicaid population in alabama, georgia, and maine. Journal of Public Health Management and Practice, 2016; 22(1):40-7. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26131658
120. Baker CL, Ding Y, Ferrufino CP, Kowal S, Tan J, et al. A cost-benefit analysis of smoking cessation prescription coverage from a US payer perspective. Clinicoecon Outcomes Res, 2018; 10:359-70. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30038510
121. Richard P, West K, and Ku L. The return on investment of a medicaid tobacco cessation program in massachusetts. PLoS ONE, 2012; 7(1):e29665. Available from: https://www.ncbi.nlm.nih.gov/pubmed/22238633
122. Anraad C, Cheung KL, Hiligsmann M, Coyle K, Coyle D, et al. Assessment of cost-effective changes to the current and potential provision of smoking cessation services: An analysis based on the equiptmod. Addiction, 2018; 113 Suppl 1:96-105. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29430762
123. Cadier B, Durand-Zaleski I, Thomas D, and Chevreul K. Cost effectiveness of free access to smoking cessation treatment in France considering the economic burden of smoking-related diseases. PLoS ONE, 2016; 11(2):e0148750. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26909802
124. Igarashi A, Goto R, Suwa K, Yoshikawa R, Ward AJ, et al. Cost-effectiveness analysis of smoking cessation interventions in Japan using a discrete-event simulation. Applied Health Economics and Health Policy, 2016; 14(1):77-87. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26597111
125. Rejas-Gutierrez J, Lopez-Ibanez de Aldecoa A, Casasola M, Varela P, Quesada S, et al. Economic evaluation of combining pharmaco- and behavioral therapies for smoking cessation in an occupational medicine setting. Journal of Occupational and Environmental Medicine, 2019; 61(4):318-27. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30688765