Tobacco Use: Reducing Out-of-Pocket Costs for Evidence-Based Cessation Treatments
Findings and Recommendations
The Community Preventive Services Task Force (CPSTF) 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.
The full CPSTF Finding and Rationale Statement and supporting documents for Tobacco Use: Reducing Out-of-Pocket Costs for Evidence-Based Cessation Treatments are available in The Community Guide Collection on CDC Stacks.
Intervention
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 CPSTF 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). This finding updates and replaces the 2000 Task Force finding on Reducing Client Out-of-Pocket Costs.
Study Characteristics
- 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.
- 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.
Summary of Results
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)
Summary of Economic Evidence
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
- 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 implementers.
Applicability
Findings of this review should be applicable to the general population of tobacco users with health care coverage in the United States.
Evidence Gaps
Intervention Design:
- Additional studies could explore thresholds for benefit use based on the amount of patient costs and co-pays.
- Does effectiveness differ by the ultimate provider of the cessation benefit change?
- Does provision of first dollar healthcare coverage for evidence-based cessation treatments affect patient use, provider use, and effectiveness?
Intervention Promotion:
- Studies should describe and evaluate efforts to promote awareness and use of tobacco cessation coverage. Evaluations of new or modified cessation benefits should include measurements to examine changes in benefit awareness among patients and providers as well as measurements to capture change in patient use of the cessation benefit.
Intervention Evaluation:
- Assessments of new or modified cessation benefits should define and enumerate the covered population, and examine changes in awareness, use, and cessation using both rates and absolute counts. Effectiveness and economic comparisons should be based on the total number of tobacco users who successfully quit within a defined population, and not just on differences in quit rates.
- Reducing out-of-pocket costs for evidence-based cessation treatments might be one approach to reduce tobacco-related disparities among population groups with health care coverage (such as Medicaid clients). Additional studies could provide additional evidence on the effectiveness of these interventions by age, sex, socioeconomic status (SES), and race/ethnicity. Modeling studies could examine relative differences in population impact between new or modified cessation benefits and current or enhanced cessation treatments offered through quitlines (which can provide evidence-based cessation treatments to tobacco users without access to health care coverage or services.
Implementation Issues:
- Studies should examine and describe barriers to client use of new or modified cessation benefits, and implement and evaluate efforts to reduce remaining barriers.
- Studies should examine and describe barriers to providers’ use of evidence-based cessation treatments for their patients who use tobacco.
- What are the effects on use and effectiveness when coverage for cessation medications is tied to participation in other treatments?
Economic Evaluation:
- Economic assessments should include the costs of promotion and examine the economic implications of ROPC programs and policies based on the promotion effort.
- Studies could also examine costs, impact, and economic implications of cessation benefits in comparison with cessation services provided by quitlines.
Implementation Considerations and Resources
- 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).
Crosswalks
Healthy People 2030 includes the following objectives related to this CPSTF recommendation.