Commentary on Vemer et al. (2010): When is smoking cessation really cost-effective?
Version of Record online: 6 MAY 2010
© 2010 The Author. Journal compilation © 2010 Society for the Study of Addiction
Volume 105, Issue 6, pages 1098–1099, June 2010
How to Cite
SALIZE, H. J. (2010), Commentary on Vemer et al. (2010): When is smoking cessation really cost-effective?. Addiction, 105: 1098–1099. doi: 10.1111/j.1360-0443.2010.02967.x
- Issue online: 6 MAY 2010
- Version of Record online: 6 MAY 2010
- policy analysis;
- smoking cessation
Studying the mechanisms of cost-effective smoking cessation strategies is a war on at least two fronts for researchers. On one hand, they have to deal with the methodological pitfalls of usually small study samples or insufficient administrative data that must represent a population suffering from a widespread disease, in order to calculate complex cost-effectiveness or cost–utility models that are not easy to communicate to clinically orientated peers or a wider public. On the other hand, relevant studies must incorporate the multi-faceted subtleties of health care policies of smoking cessation support that vary internationally to a significant—if not absurd—degree, as shown in the paper by Vemer et al.. Even on a national level, these policies may differ substantially. Politicians and health insurance carriers seem to be peculiarly careless about which strategy to follow regarding the reimbursement of costs for smoking cessation therapies.
In light of the fact that tobacco misuse is a serious and potentially life-threatening disorder, coded in the ICD-10 and calling for professional treatment, this is the actual scandal, not the lack of scientific evidence on the effectiveness of cessation programmes often claimed by decision makers when searching for an alibi for their indifference.
Most probably this is due to the ambivalent attitude and behaviour of decision makers with regard to tobacco consumption. In many countries, taxes on tobacco are significantly higher than those on all sorts of alcoholic spirits and contribute substantially to internal revenues. This conflict of interests weakens the impact of studies demonstrating that smoking cessation support works and is cost-effective, such as the paper by Vemer and co-workers. Their very accurate study joins a burgeoning body of work from recent years that shows clearly that reimbursing expenditures for smoking cessation aids increases quitter rates and has an enormous long-term public health impact. The cost per quality-adjusted life year (QALY) in all these studies lies far below international thresholds for considering a treatment as cost-effective and clearly within the range that industrialized countries are willing to pay for an additional health gain. As indispensable as studies are in this field, and as crucial as it is for them to follow exactly the guidelines for health economy research—and Vemer and colleagues have performed an extremely good and thorough job in this regard—the actual mysteries that need to be analysed are the mechanisms of how societies determine which interventions are truly worth the cost they are willing to pay.
However, this question exceeds the scope of the ordinary clinical or cost-effectiveness study to a certain degree. Clearly, increasing society's willingness to pay for health care is not a simple mathematical operation, nor is it amplified automatically by more research evidence on the cost-effectiveness of the treatment in question.
So what should be done? Of course, no cost-effectiveness or cost–utility study should violate the guidelines for good health economic research, and findings or limitations need to be presented properly. However, instead of discussing extensively the methodological details of the approach and drawing only the most puristic conclusion regarding the consequences for health care planning or politics—as employed in this paper—the perspective could be shifted a little. To outline in more detail the negative public health impact when not implementing demonstrably cost-effective treatments into routine care does not necessarily exceed the technical or methodological constraints of a scientific paper such as this one. On the contrary, it would increase its impact and grant the findings the relevance they actually deserve.
Additionally, parameters fed into sensitivity analyses could correspond to the highest and/or lowest expenditures that health insurance companies or other payers would finance for the treatment in question to reflect exactly the health policy conditions of the very system in which the study is conducted.
Finally, when discussing the options for strengthening the political impact of cost-effectiveness or cost–utility findings, the appropriateness of QALYs as a global outcome criteria for health economy studies could be questioned. QALYs have a certain tendency to conceal or play down negative health consequences when there is a need to accentuate them, as is clearly the case with regard to nicotine abuse. However, considering the widespread application of the QALY concept, this would require a much deeper methodological debate among the international scientific community.