Reducing Tobacco Use and Secondhand Smoke Exposure: Reducing Out-of-Pocket Costs for Evidence-Based Cessation Treatments
Task Force Finding
The Community Preventive Services Task Force recommends policies and programs to reduce tobacco users' out-of-pocket costs for evidence-based cessation treatments based on strong evidence of effectiveness in increasing the number of tobacco users who quit.
Evidence is considered strong based on findings from clinic-based trials and population-based policy evaluations of reduced out-of-pocket costs for both cessation counseling and medications. Clear communication of benefit changes to both tobacco users and healthcare providers increases use and impact of these interventions.
Read the full Task Force Finding and Rationale Statement for details including implementation issues, possible added benefits, potential harms, and evidence gaps.
Reducing tobacco users' out-of-pocket costs involves policy or program changes that make evidence-based treatments, including medication, counseling or both, more affordable. To achieve this, new benefits may be provided, or changes may be made to the level of benefits offered that reduce costs or co-payments.
Policy and program changes may be communicated to tobacco users and health care providers to increase awareness, interest in quitting, and use of evidence-based treatments.
About the Systematic Review
The Task Force finding is based on evidence from a Community Guide systematic review published in 2001 (Hopkins, et al., search period 1980-May 2000) combined with more recent evidence (search period January 2000-July 2012). The systematic review was conducted on behalf of the Task Force by a team of specialists in systematic review methods, and in research, practice, and policy related to reducing tobacco use and secondhand smoke exposure. This finding updates the previous Task Force finding on Reducing Client Out-of-Pocket Costs.
Eighteen studies were included in the review (5 from the previous review and 13 from the more recent search period). Included studies offered evidence-based treatments identified in Treating Tobacco Use and Dependence: 2008 Update (Fiore et al., 2008).
- Quit rates among tobacco users at follow-up periods of 3.5 months or longer: median absolute increase of 4.3 percentage points (interquartile interval [IQI]: 0.2 to 6.0 percentage points; 12 studies)
- Quit attempt rates: median absolute increase of 2.8 percentage points (IQI: -0.6 to 9.1 percentage points; 6 studies)
- Use of evidence-based cessation treatments among tobacco users attempting to quit: median absolute increase of 7.0 percentage points (IQI: 1.4 to 18.3 percentage points; 11 studies)
- Reductions in the prevalence of tobacco use were seen in two different populations (state employees and retirees in Wisconsin; Medicaid recipients in Massachusetts) after the provision of a new tobacco cessation benefit (2 studies).
- In 13 of the 18 included studies, evidence-based treatments provided at reduced out-of-pocket cost included both medications and counseling. In the remaining five studies, only medications were provided at no or reduced out-of-pocket cost.
- In the remaining five studies, only medications were provided at no or reduced out-of-pocket cost.
- Nine of the included studies were randomized controlled trials while the remaining studies were primarily a mix of cohort and time-series designs.
- Fifteen of the included studies were conducted in the United States, while the remaining studies were conducted in Germany, the Netherlands, and the United Kingdom.
Findings of this review should be applicable to the general population of tobacco users' with health care coverage in the United States.
Fifteen studies were included in the economic review. Estimates of cost-effectiveness were assessed in comparison to a conservative threshold of $50,000 per quality adjusted life year (QALY) saved. All monetary values from studies are reported in 2010 U.S. dollars.
- Cost-effectiveness estimates were provided in 5 studies.
- Cost per QALY saved: median estimate $2,349/QALY (range of values: $1,290 to $24,647; 3 studies)
- Cost per life year saved: $5,990 (1 study)
- Cost per disability adjusted life year (a measure of life lost to death and disability) averted: $7,695 to $16,559 (1 study)
- Cost-benefit comparisons were included in 10 studies.
- Eight out of 10 studies found that benefits of these interventions exceeded costs within 10 years. Estimate differences were attributable to the program provider (employer or insurer), type and duration of the cessation benefits implemented, and assumptions used to calculate savings.
- One study evaluated the Medicaid population in Massachusetts and found net savings from reduced hospitalizations for cardiovascular conditions within 2 years, with a return of $3.12 for every $1 spent.
Overall, the economic evidence indicates that interventions to reduce out-of-pocket costs for evidence-based cessation treatments are cost-effective and may provide net savings to the implementer.
Considerations for Implementation
The following considerations are drawn from studies included in the evidence review, the broader literature, and expert opinion. The Community Guide does not conduct systematic reviews of implementation.
- Awareness of a new or improved cessation benefit among both clients and providers is essential for effective implementation.
- In one Medicaid survey from 2000, cessation benefit awareness was only 36% among client tobacco users and only 60% among healthcare providers (McMenamin et al, 2004).
- The broader literature considered in this review identified a number of potential barriers to the implementation and use of these interventions.
- Health systems, insurers, and plans may be concerned that establishing a cessation benefit will lead to abrupt or unpredictable increases in treatment use.
- Both clients and their providers may be under-informed or confused about new or existing benefits, or find additional pre-authorization, prescription, or referral requirements as barriers to successful use.
- The Task Force also recommends quitline interventions. Quitlines and interventions to reduce client out-of-pocket costs have the potential to increase the use of evidence-based cessation treatments by tobacco users interested in quitting, and provide opportunities for both complementary coverage (quitlines are an accessible resource for tobacco users without access to health care services) and synergistic services (health care systems and providers can provide or encourage the use of quitline counseling as an additional component to their own cessation assistance).
- Analytic Framework [PDF - 70 kB]
- Evidence Gaps
- Summary Evidence Table - Effectiveness Review [PDF - 201 kB]
- Summary Evidence Table - Economic Review [PDF - 150 kB]
- Included Studies - Effectiveness Review
- Included Studies - Economic Review
- Search Strategy
Full peer-reviewed articles of this systematic review will be posted on the Community Guide website when published. Subscribe to be notified when we post these publications or other materials. See our library for previous Community Guide publications on this and other topics.
Community Guide News
- Quitlines, Lower Treatment Cost, and Mass Communication Help People Stop Tobacco Use
Developed by The Community Guide in collaboration with CDC's Office on Smoking and Health
More promotional materials for Community Guide reviews about Reducing Tobacco Use and Secondhand Smoke Exposure.
Hopkins DP, Briss PA, Ricard CM,Husten CG, Carande-Kulis VG, Fielding JE, Alao MO, McKenna JW, Sharp DJ, Harris JR, Woollery TA, Harris KW. Reviews of evidence regarding interventions to reduce tobacco use and exposure to environmental tobacco smoke [PDF - 6.5 MB]. Am J Prev Med 2001;20(2S):16-66.
Fiore MC, Jaen CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville (MD): U.S. Department of Health and Human Services, Public Health Service. May 2008.
The findings and conclusions on this page are those of the Community Preventive Services Task Force and do not necessarily represent those of CDC. Task Force evidence-based recommendations are not mandates for compliance or spending. Instead, they provide information and options for decision makers and stakeholders to consider when determining which programs, services, and policies best meet the needs, preferences, available resources, and constraints of their constituents.
The content of publications of the Guide to Community Preventive Services is in the public domain. Citation as to source, however, is appreciated. Sample citation: Guide to Community Preventive Services. Reducing tobacco use and secondhand smoke exposure: reducing out-of-pocket costs for evidence–based tobacco cessation treatments. www.thecommunityguide.org/tobacco/outofpocketcosts.html. Last updated: MM/DD/YYYY.
Review completed: August 2012
- Page last reviewed: May 19, 2016
- Page last updated: May 19, 2016
- Content source: The Guide to Community Preventive Services