Introduction

Cigarette smoking causes multiple diseases and reduces the general level of health of smokers (U.S. Department of Health and Human Services [USDHHS] 2004, 2014). These health consequences have been well documented in previous Surgeon General’s reports. The 1964 report first summarized results on smoking and all-cause mortality, finding that smoking causes a 70% increase in risk of adverse health consequences (U.S. Department of Health, Education, and Welfare [USDHEW] 1964). The 2004 report found smoking generally diminishes health (USDHHS 2004). General measures of health can be informative because they provide an integrative indicator of the health burden placed on smokers and on society overall. In addition to the direct human costs that smoking places on persons and society, one general measure with acknowledged implications for public health policy and practice is the economic cost of smoking.

This chapter considers broad indicators of burden in relation to smoking cessation, including morbidity, mortality, and economic costs. Initially, it considers how general indicators of health can change after smoking cessation. This type of information is critical to informing smokers about the potential benefits of cessation and serves as a strong rationale to provide interventions that can help increase the success of quitting smoking. Such programs may be offered through healthcare organizations, communities, states, and other organizations. Smoking is known to generate healthcare and other economic costs and to affect the economics of the households of smokers (USDHHS 2014). Previous Surgeon General’s reports on tobacco have periodically reviewed the economic costs of smoking, as tracked by the Centers for Disease Control and Prevention’s (CDC’s) Smoking-Attributable Mortality, Morbidity, and Economic Costs (SAMMEC) model. This chapter expands on this work by focusing on the most recently available scientific literature on the economic benefits of smoking cessation, while also complementing the kinds of cost estimates previously provided by SAMMEC.

Benefits of Smoking Cessation on Overall Morbidity

Chapter 4 of this report (The Health Benefits of Smoking Cessation) describes the associations between smoking cessation and changes in risk for specific disease outcomes. It also addresses how cessation affects the natural history of various disease outcomes, such as by slowing the progression of underlying pathophysiological processes. In addition to the beneficial impacts on specific disease outcomes, previous reviews of smoking cessation and morbidity (Goldenberg et al. 2014) have concluded that cessation is associated with improvement in health-related quality of life (HRQoL), a broad construct defined by Healthy People 2020 as “a multi-dimensional concept that includes domains related to physical, mental, emotional, and social functioning” (Office of Disease Prevention and Health Promotion 2018). In a complementary conclusion, after evaluating a broad range of general evidence, the 2004 Surgeon General’s report concluded that active smoking is causally associated with diminished health status (USDHHS 2004).

This chapter addresses the evidence on smoking cessation and its relationship to more general measures of health outcomes, particularly whether cessation improves general QoL compared with continued smoking. This review aligns with and complements the approach used in previous Surgeon General’s reports on smoking, including the 2014 Surgeon General’s report (USDHHS 2014). However, to limit the scope of this review, some of the many correlates of well-being (e.g., absenteeism from work) are not specifically considered.

Description of the Literature Review

Scientific literature from 1990 to 2017 was systematically reviewed, and reference lists from the identified articles were searched for additional studies. Search terms included “smoking cessation,” “epidemiology,” “morbidity,” “health status,” and “quality of life.” Studies were included if they measured the benefit of smoking cessation for general morbidity in former cigarette smokers; thus, the appropriate comparison group was continuing cigarette smokers but not never smokers. Accordingly, only studies that specifically and directly compared outcomes between former cigarette smokers (defined in multiple ways) and current cigarette smokers were considered. Studies that included former cigarette smokers but used only never smokers as the reference group were not included because such studies were not informative for the purpose of this chapter. However, when informative comparisons were made in eligible studies that met the criterion of comparisons with current smokers, some findings for never smokers were included.

Following the systematic review of literature, 24 studies published from 1995 to 2016 were identified that assessed smoking cessation and general morbidity, including 7 cross-sectional studies (Table 5.1) (Tillmann and Silcock 1997; Olufade et al. 1999; Mulder et al. 2001; Bolliger et al. 2002; Mody and Smith 2006; Heikkinen et al. 2008; McClave et al. 2009) and 16 prospective cohort studies (Tables 5.2–5.4) (Stewart et al. 1995; Taira et al. 2000; Bolliger et al. 2002; Zillich et al. 2002; Erickson et al. 2004; Mitra et al. 2004; Croghan et al. 2005; Wiggers et al. 2006; Jensen et al. 2007; Rungruanghiranya et al. 2008; Gutiérrez-Bedmar et al. 2009; Balduyck et al. 2011; Papadopoulos et al. 2011; Hays et al. 2012; Piper et al. 2012; Tian et al. 2016).

Table 5.1

Cross-sectional studies about smoking status and quality of life.

Table 5.2

Prospective studies about smoking status and quality of life.

Table 5.4

Prospective studies of special populations.

Assessment of Morbidity

The general measures of morbidity used in the 24 identified studies varied but cover three main categories: general, smoking specific, or disease specific:

1. General. Many studies used general measures of HRQoL, most frequently the Short Form (SF)-36 (SF-36) and SF-12 surveys, both the Medical Outcomes Study (Ware Jr and Sherbourne 1992) and RAND versions (Hays and Morales 2001). One study (Mitra et al. 2004) adapted the SF-36 for use in a population with mobility impairments. The other generic measures of HRQoL included the 15-D (dimensional) (Sintonen 1995), the EuroQoL (The EuroQol Group 1990), the QoL Inventory (Frisch et al. 1992), the World Health Organization’s QOLBREF (Skevington et al. 2004), CDC’s HRQOL-4 and its Healthy Days Symptoms Module (Moriarty et al. 2003), and the Functional Status Questionnaire (Jette et al. 1986). The studies identified in the literature review also assessed dissatisfaction with life and general health status.
2. Smoking specific. One study (Olufade et al. 1999) used the Smoking Cessation Quality of Life (SCQoL) questionnaire.
3. Disease specific. Some studies used disease-specific measures of HRQoL. These measures assess the impact of specific diseases on relevant components of QoL. The European Organisation for Research and Treatment of Cancer (EORTC) QoL Questionnaire QLQ-C30 (Aaronson et al. 1993) was used, along with the LC13 module for lung cancer (Bergman et al. 1994) and the H&N35 module for head and neck cancer (Bjordal et al. 1994). Other disease-specific instruments included the Aquarel questionnaire for patients with pacemakers (Stofmeel et al. 2001), the Clinical COPD Questionnaire (van der Molen et al. 2003), and the VascuQoL questionnaire for patients with peripheral arterial disease (Morgan et al. 2001).

Assessment of Smoking Status

Most of the 24 identified studies assessed cigarette smoking status by self-report. Self-reported smoking status continues to be sufficiently valid and reliable for studying the general population but may be less accurate for assessing smoking in high-risk or medical patients (Velicer et al. 1992; USDHHS 2004, 2014).

All of the studies determined whether participants were former smokers, but the period of abstinence from smoking required for classification as a former smoker was not uniform across studies, and some studies did not specify a minimum time period of abstinence (McClave et al. 2009; Tian et al. 2016). Some studies confirmed smoking status by a biomarker, such as cotinine (Stewart et al. 1995) or carbon monoxide (Zillich et al. 2002; Rungruanghiranya et al. 2008; Hays et al. 2012; Piper et al. 2012). Several studies (Stewart et al. 1995; Croghan et al. 2005; Wiggers et al. 2006; Piper et al. 2012) defined abstinence as a period of 7 days without smoking, but others used different standards, including 2 weeks (Olufade et al. 1999), 1 month (Mitra et al. 2004; Heikkinen et al. 2008), 3 months (Rungruanghiranya et al. 2008), and 5 years (Tillmann and Silcock 1997). One study, Erickson and colleagues (2004), considered level of addiction and divided former smokers into subgroups of low and high addiction, as assessed by the Fagerström Test for Nicotine Dependence (FTND) (Heatherton et al. 1991).

Some variation was also observed with regard to comparison groups used across studies. For example, as the reference group for comparing outcomes among those who had quit successfully, McClave and colleagues (2009) used unsuccessful quitters, defined as those who had attempted to quit at least once in the past year but were currently smoking. In a clinical trial of nicotine replacement therapy (NRT), Bolliger and colleagues (2002) compared successful reducers, who were ongoing smokers who had achieved at least a 50% reduction in the number of cigarettes smoked daily from week 6 to month 24 of the trial, with unsuccessful reducers.

Epidemiologic Evidence

Cross-Sectional Studies

Table 5.1 summarizes cross-sectional studies of smoking cessation and morbidity. Seven cross-sectional studies assessed smoking cessation and morbidity by asking participants to self-report smoking status and a measure of morbidity at the time of survey. Several studies that used the SF-36 to assess HRQoL observed that having quit smoking was associated with higher scores on some measures. Tillmann and Silcock (1997), in a study of 3,000 participants, reported significantly higher HRQoL, as measured by SF-36 and EuroQoL tariff scores, among former smokers who had smoked 5 years or more compared with current smokers in Scotland. Olufade and colleagues (1999), in a sample of 101 adults, reported that former smokers (smokefree for 2 or more weeks) had significantly higher scores on physical functioning, vitality, general health, and the Physical Component Summary compared with current smokers; however, they found no significant differences for other measures on the SF-36. In the Netherlands, Mulder and colleagues (2001) reported significantly higher HRQoL scores for former smokers on all measures of the SF-36, except bodily pain compared with current smokers. In their sample, the HRQoL of former smokers approached that of never smokers, and adjusted mean scores on measures of the SF-36 did not differ significantly between never smokers and former smokers, except for bodily pain. Mulder and colleagues (2001) also found that increasing years since quitting was associated with higher scores on general health, vitality, mental health, and the Mental Component Summary. These researchers noted that overall differences in QoL between former smokers and current smokers were more pronounced for measures of mental health than for physical health. Although the first three studies found various differences by smoking status using the SF-36, in a representative sample of adults older than 14 years of age in Spain, Bellido-Casado and colleagues (2004) found no differences by smoking status in measures of physical, emotional, or mental health in the SF-36.

Two studies used data from the Behavioral Risk Factor Surveillance System (BRFSS), a telephone-based survey of U.S. adults 18 years of age and older. In an analysis of data from 2001 from a representative sample of 209,031 adults, Mody and Smith (2006) found that, compared with nonsmokers and former smokers, current cigarette smokers were more likely to experience (in the past 30 days) 14 or more days of activity limitation, 14 or more days of poor physical health, and 14 or more days of poor mental health. In addition, in their comparisons with former smokers, they found that current smokers were more likely to report poor general health. McClave and colleagues (2009), who used BRFSS data from 2006 in four states, found that former smokers and nonsmokers were less likely than current smokers (nonquitters) to report life dissatisfaction and frequent depressive symptoms; however, there were no significant differences between current and former smokers in reported general health status, frequent anxiety symptoms, frequent mental distress, frequent physical distress, frequent activity limitations, frequent pain, infrequent vitality, or frequent sleep impairment. Among men, there were no significant differences in HRQoL between former and current smokers. Among women, reported frequent mental and physical distress did not differ significantly between former and never smokers and current smokers, but among current smokers, women who tried to quit smoking and failed were more likely to report frequent mental stress and physical distress than were women who did not try to quit.

Heikkinen and colleagues (2008) used the 15-D instrument to assess HRQoL in a nationally representative sample of about 8,000 adults 30 years of age and older in Finland. Compared with daily smokers, former smokers (defined as those who had not smoked for at least the past month) reported higher scores on most measures of the instrument.

Longitudinal Studies

Tables 5.2–5.4 summarize findings from 16 longitudinal studies of smoking cessation and general morbidity. These studies fall into three categories: (1) prospective cohort studies, (2) randomized controlled trials (RCTs), and (3) observational studies embedded within RCTs in which the data from the RCTs were analyzed as though the studies were observational without preservation of the randomization. With these types of longitudinal designs, smoking status is assessed before the outcome occurs. In contrast, cross-sectional studies assess smoking status and the outcome at the same point in time. Prospective studies were considered for quality of life (Table 5.2), populations receiving cessation treatment (Table 5.3), and populations with specific medical conditions (Table 5.4). Studies included in Table 5.2 were all designed as prospective cohorts (Stewart et al. 1995; Erickson et al. 2004; Gutiérrez-Bedmar et al. 2009; Tian et al. 2016). Table 5.3 includes studies with different longitudinal designs: prospective cohort (Zillich et al. 2002; Croghan et al. 2005), RCT (Rungruanghiranya et al. 2008; Hays et al. 2012), and observational study within an RCT (Bolliger et al. 2002; Piper et al. 2012). Table 5.4 includes longitudinal studies designed as prospective cohorts (Taira et al. 2000; Mitra et al. 2004; Jensen et al. 2007; Balduyck et al. 2011; Papadopoulos et al. 2011) or observational studies within an RCT (Wiggers et al. 2006).

Table 5.3

Prospective studies of populations undergoing cessation treatment.

Longitudinal Studies of General Populations

At the 4-year follow-up of 5,234 participants of a study based in Spain, Gutiérrez-Bedmar and colleagues (2009) found that compared with current smokers, mean scores for general, emotional, and mental health were significantly better among recent former smokers who had quit after the baseline assessment and before the 4-year follow-up. Tian and colleagues (2016) assessed HRQoL, using the SF-12, in relation to smoking status at baseline (never, former, and current smokers) and after 5 years of follow-up in about 2,000 Australian adults 31–41 years of age at follow-up. There were no significant differences in measures comparing never and former smokers at baseline, but at the 5-year follow-up, those who had continued to smoke had larger reductions in QoL scores than those who reported being former smokers at follow-up and were smokers at baseline. For these quitters, the estimated relative risk for a clinically significant improvement in physical HRQoL scores was higher compared with continuing smokers. Additionally, former smokers had a higher likelihood of a clinically significant improvement in emotional and mental health HRQoL scores compared with continuing smokers.

Longitudinal Studies of Populations Undergoing Cessation Treatment

Eight trials considered participants engaged in cessation treatment. In one, Stewart and colleagues (1995) assessed the smoking status of 323 adults enrolled in a community-based RCT of smoking cessation. At baseline, all participants were smokers. At 6 months, quitters had a significantly higher score on all assessed measures of mental health compared with continuing smokers, including psychological well-being, anxiety, positive affect, cognitive functioning, energy, sleep adequacy, self-esteem, and sense of mastery. In contrast, for the five measures of physical health, there were no statistically significant differences between the groups on four measures: physical functioning, social functioning, pain, and current health perceptions.

Zillich and colleagues (2002) used the SCQoL questionnaire to evaluate changes in HRQoL among 31 participants in a nonrandomized, unblinded trial to evaluate the effectiveness of a pharmacist-based smoking cessation program. Vitality, mental health, and self-control improved significantly among those who successfully quit over the 6 months of follow-up compared with baseline. However, data were missing for participants who did not successfully quit and did not return for follow-up. In Switzerland, Bolliger and colleagues (2002) enrolled a cohort of 400 participants from an earlier RCT of an oral nicotine inhaler for smoking reduction and examined QoL in relation to smoking reduction. Healthy adult volunteers were randomized to active or placebo inhalers and encouraged to reduce their smoking as much as possible; the cohort was followed for 24 months. The comparison group of nonreducers (less than a 50% reduction in the number of cigarettes smoked daily from week 6 to month 24) was used for comparison with successful reducers (at least a 50% reduction). Compared with the control group, successful reducers had significantly greater improvement in general health, as measured by the SF-36.

Among those who quit in a study of 34 smokers, Erickson and colleagues (2004) considered whether low (FTND score ≤6) or high (FTND score >6) levels of addiction affected QoL 1 week after the quit date. The lower addiction group showed a significant improvement in more of the HRQoL domain scores after the quit date compared with the higher addiction group.

Croghan and colleagues (2005) evaluated 206 patients treated for nicotine dependence for changes in their health status, as measured by the SF-36, 1 year after consultation at the Mayo Clinic. Patients who stopped smoking for 1 year or more had significantly higher QoL measures at baseline compared with a demographically similar group who had not stopped smoking. After controlling for baseline scores, patients who stopped smoking for 1 year or more had significantly improved scores on the Mental Component Summary and for role limitations, both emotional and physical, and significantly improved general health compared with those who were not abstinent for a year.

Rungruanghiranya and colleagues (2008) performed a placebo-controlled RCT in Thailand that considered the effectiveness of nicotine gum for cessation and examined changes in QoL after 3 months. Forty-six subjects underwent screening for the study; two were excluded because of NRT use, and one was excluded due to a recent diagnosis of diabetes. Among the 43 participants, the study revealed no significant differences in improved QoL between those who had successfully quit smoking and those who had not.

Piper and colleagues (2012) assessed QoL in 1,504 participants making a quit attempt as part of an RCT of smoking cessation. Both former smokers (i.e., quitters) and current smokers (nonquitters) experienced a reduction in global QoL at the 1- and 3-year follow-ups, but former smokers had a significantly smaller decrease in global QoL. Former smokers showed slight improvement in HRQoL at years 1 and 3, an outcome significantly different from the decreases in HRQoL reported by continuing smokers. Former smokers also reported a decrease in negative affect at 1 year, which differed significantly from the slight increase in continuing smokers.

Hays and colleagues (2012) implemented a placebo-controlled RCT in which 2,052 participants were treated with varenicline, bupropion SR (sustained release), or placebo and followed for 52 weeks. Participants in both treatment groups showed clinically relevant differences in health transition (perceived health compared with baseline) and self-control at follow-up compared with participants in the placebo group at follow-up. In terms of abstinence, those who had a longer period of abstinence reported better health transition and self-control at follow-up compared with those who were abstinent for a shorter period. Among those with a longer period of abstinence, findings were similar to those abstinent for a shorter period of time for vitality, smoking-related anxiety, and improvement in scores on the Mental Component Summary.

Longitudinal Studies of Special Populations

Table 5.4 summarizes six longitudinal studies that considered smoking cessation in special populations defined by disease status. Taira and colleagues (2000) assessed QoL after percutaneous coronary revascularization in 1,432 patients with coronary artery disease within two RCTs (Baim et al. 1998, 2001). All groups (nonsmokers, former smokers [quitters], and persistent smokers) showed improvements on measures of the SF-3, but the extent of improvement differed by smoking status. At 6 months, after controlling for baseline scores on the SF-36, improvement among former smokers was comparable to that of nonsmokers. At 1 year, persistent smokers continued to show significantly less improvement than former smokers in physical functioning, social functioning, and mental health. Compared with continuing smokers, former smokers made significantly greater gains in both Physical Component Summary and Mental Component Summary scores at 6 months and 1 year.

Using data from Wilber and colleagues (2002), Mitra and colleagues (2004) performed a longitudinal study of 355 adults with disabilities and found that changes in smoking status were associated with future changes in QoL scores—with former smokers experiencing significantly more improvement in mental health, energy and vitality, and perceived general health compared with current smokers. In the Netherlands, Wiggers and colleagues (2006) studied 344 smokers with atherosclerotic vascular disease who were participating in an RCT of NRT combined with a behavioral intervention, and considered both general (SF-36) and disease-specific QoL (Aquarel and VascuQoL). Overall, participants showed improved physical and mental QoL, as measured by SF-36 at follow-up (2, 6, and 12 months), but there were no differences by smoking status. In a study based in Denmark, Jensen and colleagues (2007) considered smoking status and QoL in 114 patients surveyed after treatment for head and neck cancer. Those who had quit smoking at postsurgical follow-up showed higher physical and mental functioning compared with continuing smokers.

In Greece, Papadopoulos and colleagues (2011) investigated smoking cessation and QoL using a disease-specific score (the Clinical COPD Questionnaire [CCQ]) in a cohort of 26 participants with chronic obstructive pulmonary disease who had successfully quit smoking for 2 months. QoL, as measured by both the CCQ and a generic scale (SF-12), improved after 2 months of cessation. Finally, Balduyck and colleagues (2011), in a study based in Belgium, considered 70 patients’ return-to-baseline QoL after surgery for lung cancer using a disease-specific score (EORTC-C30 and EORTC-LC13) that was administered after a reduction in smoking following surgery in all three smoking status groups (current smoker, former smokers, and recent quitters). Those who were former smokers at baseline (i.e., before their diagnosis) and those who quit smoking after diagnosis both showed improved QoL at follow-up compared with those who continued to smoke, although those who were former smokers at baseline had a faster return to baseline QoL than recent quitters.

Benefits of Smoking Cessation on All-Cause Mortality

Increased all-cause mortality is a well-established causal consequence of smoking (USDHHS 2004, 2014). Chapter 4 of this report (The Health Benefits of Smoking Cessation) summarizes disease risks from smoking and the changes in risk that follow smoking cessation for the major types of chronic diseases. This section briefly summarizes the well-documented and extensive scientific evidence on the health benefits of smoking cessation on all-cause mortality. The review is limited in scope because the topic has been extensively covered in prior reports.

Conclusions from Previous Surgeon General’s Reports

The 1964 Surgeon General’s report included a table on all-cause mortality with the findings of seven cohort studies. In a pioneering quantitative synthesis of the data from the seven studies, the ratio of deaths observed to deaths expected was 1.68:1 (USDHEW 1964). A contemporary analysis of the data from the 1964 Surgeon General’s report showed statistically significant increases in all-cause mortality in all of the studies (Figures 5.1a and 5.1b) (Schumacher et al. 2014). The 1964 Surgeon General’s report concluded that, “Cigarette smoking is associated with a 70 percent increase in the age-specific death rates of males, and to a lesser extent with increased death rates of females. The total number of excess deaths causally related to cigarette smoking in the U.S. population cannot be accurately estimated. In view of the continuing and mounting evidence from many sources, it is the judgment of the [Surgeon General’s Advisory Committee on Smoking and Health] that cigarette smoking contributes substantially to mortality from certain specific diseases and to the overall death rate” (USDHEW 1964, p. 31).

Figure 5.1a

Incidence rate ratios for death from any cause, by smoking status.

Figure 5.1b

Incidence rate ratios for death from lung cancer, by smoking status. Source: Schumacher and colleagues (2014). Copyright © 2014, Massachusetts Medical Society. Reprinted with permission from Massachusetts Medical Society. Note: CI = confidence (more...)

By the time of the 1964 report, evidence from five cohort studies showed lower risk for all-cause mortality in former smokers compared with current smokers, and data from several cohorts showed declining risk for death in former smokers, compared with current smokers, as the interval since cessation lengthened.

Subsequent Surgeon Generals’ reports (USDHEW 1969, ¹⁹⁷⁹; USDHHS 1989, ^{1990, 2004,} 2014) have comprehensively covered this topic and published findings comparable to those in the 1964 Surgeon General’s report. In brief, using data from the American Cancer Society’s Cancer Prevention Study II, the 1990 Surgeon General’s report included lifetable analyses on the health benefits of smoking cessation, offering the following conclusions on all-cause mortality:

• “Former smokers live longer than continuing smokers, and the benefits of quitting extend to those who quit at older ages. For example, persons who quit smoking before age 50 have one-half the risk of dying in the next 15 years compared with continuing smokers.
• Smoking cessation at all ages reduces the risk of premature death.
• Among former smokers, the decline in risk of death compared with continuing smokers begins shortly after quitting and continues for at least 10 to 15 years. After 10 to 15 years of abstinence, risk of all-cause mortality returns nearly to that of persons who never smoked” (USDHHS 1990, p. 92).

The 2004 Surgeon General’s report extended these findings by comprehensively documenting and updating the evidence on active smoking and disease, noting that “fortunately for former smokers, studies show that substantial risks of smoking can be reduced by successfully quitting at any age” (USDHHS 2004, p. 25). Furthermore, the report concluded that “quitting smoking has immediate as well as long-term benefits, reducing risks for disease caused by smoking and improving health in general” (USDHHS 2004, p. 25).

The 2014 Surgeon General’s report provided the most recent extensive review of the consequences of smoking on health and confirmed findings from previous reports in the series:

• “The evidence is sufficient to infer that cigarette smoking increases risk for all-cause mortality in men and women.
• The evidence is sufficient to infer that the relative risk of dying from cigarette smoking has increased over the last 50 years in men and women in the United States” (USDHHS 2014, p. 641).

The 2014 Surgeon General’s report also compared the relative risks for all-cause mortality in the American Cancer Society’s Cancer Prevention Studies I (1959–1965) and II (1982–1988) with those in a pooled analysis of five contemporary cohorts with follow-up through 2010. The comparison revealed rising relative risks for all-cause mortality among current smokers, both men and women, in the contemporary cohorts. Among former smokers, the relative risks were substantially lower in the contemporary cohorts compared with those in the earlier American Cancer Society cohorts. However, compared with never smokers, the relative risks for former smokers were higher in the contemporary cohorts compared with the earlier cohorts (Tables 5.5a and 5.5b).

Table 5.5a

Relative risks by smoking status and age group among adult men 35 years of age and older, United States.

Table 5.5b

Relative risks by smoking status and age group among adult women 35 years of age and older, United States.

The 2014 Surgeon General’s report also found that despite advancement in disease prevention and treatment over the past 50 years, current cigarette smokers had not experienced as much improvement in life expectancy compared with former and never smokers. Former smokers had progressively lower relative risk of all-cause mortality the younger they quit smoking (USDHHS 2014). For example, the Million Women Study found that women who quit smoking before 30 years of age and before 40 years of age avoided more than 97% and 90% of excess mortality risk, respectively, compared with those who continued smoking (Pirie et al. 2013). In an analysis of more than 216,000 adults from 1997 to 2004, Jha and colleagues (2013) found a similar relationship between smoking and survival: Smoking cessation before 40 years of age reduced the risk of death associated with continued smoking by approximately 90%. Additionally, adults who had quit smoking at 25–34, 35–44, or 45–54 years of age gained about 10, 9, and 6 years of life, respectively, compared with those who continued smoking. These findings are consistent with those reported in the 2004 and 2014 Surgeon General’s reports. Although smokers lose an estimated decade of life on average, smoking cessation by 40 years of age avoided more than 90% of the excess mortality caused by continued smoking (USDHHS 2004, ²⁰¹⁰; Pirie et al. 2013). Even quitting smoking by about 60 years of age could reduce premature mortality by 40% (USDHHS 2004, 2010).

Benefits of Smoking Cessation on Economic Costs

Cigarette smoking causes both substantial morbidity and premature mortality, resulting in significant economic costs for smokers and their families and very large costs for society in general (USDHHS 2004). Because smoking cessation reduces these costs, the comparative costs and benefits of treatments for smoking cessation will help to inform tobacco control strategies for different settings. In evaluating the economic dimensions of smoking cessation, consideration needs to be given to the specific costs and benefits generated by programs or policies that increase successful cessation. These costs and benefits, which extend into numerous sectors beyond healthcare, include the consequences for employment, such as lost productivity from active smoking, as well as for retirement benefits and pensions that may be transferred to never smokers and former smokers from early tobacco-related death among sustained smokers who do not quit (National Cancer Institute and World Health Organization 2016). This section focuses on the economic dimensions of smoking cessation, including the critical comparator: the costs of smoking.

Economics of Smoking Cessation

An economic analysis of smoking cessation must consider a variety of costs, including costs accrued by smokers before successful cessation. Although many persons can quit smoking without any assistance, others need assistance from public health programs that encourage smoking cessation, or from healthcare services that provide psychological or pharmacologic assistance to help them stop smoking. These interventions, which increase smoking cessation, also have associated costs.

Principles of Cost-Benefit and Cost-Effectiveness Analysis

Policies to encourage beneficial behaviors are often evaluated by cost-benefit analysis, which compares outcomes in terms of dollar value and prioritizes different policies, particularly when resources are scarce or funds are limited (Russell 2015). The simplest method for comparison is to derive a single estimate for each policy by converting all costs and benefits into financial measures. In healthcare, however, the full benefits associated with improved health are not easily converted into financial benefits because of challenges in the financial valuations of extending life or avoiding morbidity (Gold et al. 1996). As a result, cost-effectiveness analysis is often used in healthcare, but the measurements of effect may not always be comparable across studies. One type of cost-effectiveness analysis is cost-utility analysis, in which health benefits are based on a common metric, such as quality-adjusted life-years (QALYs) gained (Gold et al. 1996). Recommendations on cost-effectiveness in health and medicine were published in 1996 (Gold et al. 1996; Russell et al. 1996; Siegel et al. 1996; Weinstein et al. 1996) and updated in 2016 (Sanders et al. 2016).

The particular analytic perspective to choose and the evaluation of ratios are two key considerations for both cost-benefit and cost-effectiveness analyses. The analytic perspective taken can change the costs and benefits of an evaluation, because evaluations using one perspective (e.g., that of a payer) may not include the same costs or benefits as those using another perspective (e.g., that of society in general). For example, if an insurance plan accrues the costs of paying for a smoking cessation program but does not reap the benefits from cessation because persons frequently switch insurance plans, such switching may result in a less cost-effective scenario for the plan. From a societal perspective, however, benefits are accrued from all persons who quit successfully, regardless of switches in insurance plans. Gold and colleagues (1996) recommended the societal perspective as the appropriate analytic perspective to provide a full accounting of costs and benefits, but other perspectives, such as that of the payer when a program to promote smoking cessation is implemented, may be the focus of an analysis. Sanders and colleagues (2016) recommended considering components of cost from an analytical perspective (e.g., from health sector and societal perspectives).

To assess the cost-effectiveness of an intervention, the incremental cost-effectiveness ratio is calculated and evaluated. The ratio estimates how much extra cost is needed for an intervention compared with alternatives (control or next best alternative in terms of effectiveness) to derive an extra unit of benefit (e.g., QALY). To compare the relative value of multiple policy interventions, both absolute cost-effectiveness ratio (the ratio of the cost of intervention minus costs averted by the intervention, divided by QALYs gained, where the comparison is between an intervention and a “do nothing” or control) and incremental cost-effectiveness ratio (the ratio of costs of interventions minus costs averted by the intervention, divided by QALYs gained, where the comparison is between an intervention and the next best intervention) can be estimated (Cohen and Reynolds 2008). When evaluating one intervention versus a control, the absolute cost-effectiveness and incremental cost-effectiveness are the same. However, an evaluation of multiple interventions should be based on incremental cost-effectiveness ratios. Relying only on absolute cost-effectiveness ratios can distort estimates and result in invalid conclusions. The absolute cost-effectiveness ratios of alternative interventions can be similar and cost-effective when compared with an acceptable threshold. However, when the incremental cost-effectiveness ratio for an alternative is evaluated and compared with the next best alternative, the alternative may not necessarily be cost-effective— even if it is cost-effective when compared with the control.

An international consortium that evaluated the relative costs and benefits of a range of smoking cessation interventions found that in a high-income country, such as the United States, such interventions as automated text messaging, self-help materials, and brief advice from a physician have a low cost but only small effects on smoking cessation. Conversely, pharmacological and psychological interventions (either by telephone or provided in person) are higher in cost but have greater effects on increasing smoking cessation (West et al. 2015). In another examination of relative costs and benefits that used a much different framework to gauge benefit, disability-adjusted life-years gained, Jha and colleagues (2006) found that NRT may be more cost-effective than other interventions—its higher price notwithstanding. A systematic review on the economic impact of a conservative 20% price increase of tobacco products through taxation found evidence of per capita cost savings over the short- and medium terms (Contreary et al. 2015).

Because of their relatively high cost, pharmacologic and psychologic smoking cessation interventions have been more closely evaluated than inexpensive interventions. This report summarizes the cost-effectiveness ratios gleaned from the review of literature on the cost-effectiveness of clinical cessation interventions and compares the estimates to a threshold of cost-effectiveness for clinical interventions used in healthcare (Neumann et al. 2014; Sanders et al. 2016).

Cost-Effectiveness of Clinical Smoking Cessation Interventions

In a systematic review of the literature, Ruger and Lazar (2012) summarized the evidence on the cost-effectiveness of smoking cessation through 2009. This review covered literature indexed in PubMed and the British National Health Service’s Economic Evaluation Database as containing an economic evaluation (cost-benefit, cost-effectiveness, cost-utility, or cost-minimization analysis) of pharmacotherapy or counseling for smoking cessation. The review examined 36 economic evaluations in detail, including 14 studies of NRT, 12 studies of non-nicotine-based pharmacotherapy, and 10 studies of brief counseling for smoking cessation. The review found that cost-effectiveness and other types of economic evaluation studies do not routinely use standard metrics to evaluate benefits and often use the payer’s perspective, not the societal perspective as recommended (Tables 5.6–5.8). To standardize dollar value of costs to the same base year, estimates in this section were converted to 2017 U.S. dollars from the base case year (or publication year if the base case year was not known) using the Medical Care part of the Consumer Price Index (all urban consumers). When performing benefit-cost analyses, USDHHS typically values QALY gains at about $500,000 or $850,000, depending on the discount rate applied (USDHHS 2016). This is substantially larger than the recently recommended values of $100,000 or $150,000 per QALY gained (Neumann et al. 2014).

Table 5.6

Summary of economic evaluations of nicotine-based pharmacotherapies for smoking cessation.

Table 5.8

Summary of economic evaluations of brief counseling for smoking cessation.

Table 5.6 summarizes studies on nicotine-based pharmacotherapies. For NRT, RCTs in the United Kingdom estimated that when NRT was added to brief counseling in primary care settings, incremental cost per life-year saved ranged from $1,115 to $2,541 depending on the age groups from the national health system perspective (Stapleton et al. 1999). According to two more recent studies, the cost of NRT per additional quitter was $171 compared with usual care from the health insurance perspective (Salize et al. 2009) and was $3,781 compared with brief counseling from the state program perspective (Hollis et al. 2007). In an examination of observational data, adding free NRT to quitline counseling in the United States resulted in incremental costs of $132 per life-year saved and $267 per quit attempt in Oregon from the program perspective (Fellows et al. 2007) and of $808 per quit attempt in Minnesota from the funding agency perspective (An et al. 2006). Three studies that used decision-analytic modeling found incremental cost-effectiveness ratios ranging from $9,463 to $23,589 per QALY gained for physician-based cessation counseling with nicotine patch compared with counseling alone from the payer perspective (Fiscella and Franks 1996), $2,388 to $9,791 per QALY gained from the societal perspective (Cromwell et al. 1997), and $2,511 to $6,020 per life-year saved for NRT compared with counseling or advice alone from the national health services perspective (Song et al. 2002).

Five studies that modeled populations of smokers estimated incremental cost-effectiveness ratios for counseling and NRT compared with brief physician counseling alone ranged from $1,267 to $42,160 per life-year saved from the payer perspective (Oster et al. 1986; Wasley et al. 1997; Gilbert et al. 2004; Cornuz et al. 2006) and from $2,021 to $9,002 per QALY gained from the societal perspective (Feenstra et al. 2005). Among two studies on pharmacist-directed smoking cessation programs, one involving only the receipt of advice and motivation compared with usual advice from a pharmacist found cost-effectiveness ratios ranging from $628 to $2,678 per life-year saved from the payer perspective (Crealey et al. 1998), and the other incorporating four methods under pharmacist direction (quitting cold turkey, two kinds of NRT, and bupropion) compared with self-directed quit attempts found cost-effectiveness ratios ranging from $478 to $2,496 per successful quit from the payer perspective (Tran et al. 2002).

Table 5.7 summarizes cost-effectiveness studies of non-nicotine-based pharmacotherapies. Five studies evaluated varenicline and compared it with different comparators (nortryptiline; bupropion, NRT, and unaided cessation; brief counseling alone and unaided cessation; counseling; or NRT). Incremental cost-effectiveness ratios ranged from $1,409 to $5,838 per quit attempt from the healthcare system perspective (Hoogendoorn et al. 2008) and from dominates (i.e., less costly and more effective) to $4,981 per QALY gained from the healthcare payer/system perspective (Hoogendoorn et al. 2008; Howard et al. 2008; Annemans et al. 2009; Bolin et al. 2009b; Igarashi et al. 2009). In some trials, varenicline was more efficacious than the comparison strategy (whether unaided cessation or cessation with NRT or bupropion) and more cost-effective from various perspectives (healthcare payer/system) (Howard et al. 2008; Annemans et al. 2009; Bolin et al. 2009b; Igarashi et al. 2009). Two other studies also showed that an extended period of varenicline treatment compared with placebo or 12 weeks of varenicline, bupropion, or NRT was less costly and more effective per QALY gained from the healthcare perspective (Knight et al. 2010) and was more effective than placebo, with incremental cost-effectiveness ratios as high as $41,053 per QALY gained from the societal perspective (Bolin et al. 2009a). Studies comparing bupropion with NRT found incremental cost-effectiveness ratios as high as $1,223 per QALY gained from the societal perspective (Bolin et al. 2006). One study compared bupropion with counseling or advice alone and found that the incremental cost per life-year saved ranged from $1,603 to $3,746 from a national health system perspective (Song et al. 2002).

Table 5.7

Summary of economic evaluations of non-nicotine-based pharmacotherapies for smoking cessation.

Table 5.8 summarizes 10 studies that evaluated brief counseling therapies conducted with a variety of methods, in diverse settings, and with diverse populations. Using data from RCTs, an evaluation of care that included 20 minutes of bedside counseling, 12 minutes of videos, self-help materials, and follow-up calls found that incremental cost-effectiveness ratios ranged from $3,809 to $16,769 per life-year saved compared with usual care from the implementing hospital perspective (Meenan et al. 1998), and another evaluation of stepped cessation services found that ratios per life-year gained ranged from $8,271 to $15,327 compared with brief contact from the healthcare perspective (Barnett et al. 2008). Three evaluations of counseling therapies per additional quit found that the incremental cost-effectiveness ratio was $8,382 from the implementing hospital perspective (Meenan et al. 1998) and that cost-effectiveness ratios ranged from $9,926 to $18,392 from the healthcare perspective (Barnett et al. 2008) and from $1,259 to $2,061 from the societal perspective (Akers et al. 2007). Using an observational design, Boyd and Briggs (2009) found incremental cost-effectiveness ratios per QALY gained of $11,671 for one-toone support (by a pharmacist) and $14,324 for group counseling, and found incremental cost-effectiveness ratios per quit of $2,047 and $2,922 for one-to-one support and for group counseling, respectively, compared with self-quit cessation attempts from the national health system perspective. In other studies that compared brief counseling or smoking cessation programs with usual care, estimated incremental cost-effectiveness ratios ranged from $499 to $1,875 per life-year saved from the school perspective (Dino et al. 2008), from $735 to $903 from the health-care perspective (Thavorn and Chaiyakunapruk 2008), and from $3,138 to $9,159 per life-year saved from the societal perspective (Cummings et al. 1989). Additionally, the incremental cost-effectiveness ratio was $4,130 per QALY gained from the societal perspective (Solberg et al. 2006).

Cost-Effectiveness of Nonclinical Smoking Cessation Interventions

Table 5.9 summarizes studies on the cost-effectiveness of various policy interventions that promote smoking cessation. To standardize the dollar value of costs to the same base year, estimates in this section were converted to 2017 U.S. dollars from the base case year (or publication year if no base case year) using the Medical Care part of the Consumer Price Index (all urban consumers). Although these studies share this focus, the evaluations were highly heterogeneous (Ekpu and Brown 2015). Regardless, some of these evaluations estimated cost-effectiveness ratios similar to or greater than those for clinical smoking cessation interventions. The estimated incremental cost-effectiveness ratios for an NRT program and for a smoke-free workplace policy compared with the clinical standard were $7,736 and $882 per QALY gained, respectively (Ong and Glantz 2005). Villanti and colleagues (2012) evaluated the American Legacy Foundation’s national EX campaign, which was a radio and television campaign from 2008 designed to promote smoking cessation among adult smokers. The estimated incremental cost-effectiveness ratios ranged from $47,271 to $102,883 per QALY gained from the societal perspective when compared with a hypothetical status quo of no program or change in cessation behavior. School-based antitobacco education programs compared with status quo have a much wider range of estimated incremental cost-effectiveness ratios per QALY gained over 50 years, ranging from $9,294 when considering a 56% reduction in smoking that dissipates in 4 years to $644,890 when considering a 5% reduction in smoking that dissipates in 1 year from the societal perspective. For the most plausible scenario of 30% effectiveness in preventing smoking, which dissipates in 4 years, the estimated cost-effectiveness ratio was $37,935 per QALY gained (Tengs et al. 2001). In a study evaluating CDC’s Tips From Former Smokers (Tips) Campaign among adults, Xu and colleagues (2015a) estimated an incremental cost-effectiveness ratio of $450 per life-year saved and $307 per QALY gained in the short run from the funding agency’s perspective compared with not having the campaign.

Table 5.9

Summary of economic evaluations of nonclinical interventions for smoking cessation.

Cost-Effectiveness of Tobacco Price Increases Through Taxation

Contreary and colleagues (2015) conducted a systematic review of the cost-effectiveness of a tobacco price increase through taxation and found only one study that evaluated the cost-effectiveness per QALY gained. The study found that the cost-effectiveness ratio for a 10% increase in per unit price of tobacco through a 15% increase in excise tax was $3,839 (2017 dollars) per QALY gained over 100 years from the healthcare perspective (van Baal et al. 2007).

Summary of the Evidence

This chapter examines morbidity, mortality, and economic costs in relation to smoking cessation. For general measures of health outcomes, particularly general QoL, there is evidence of higher levels of improvement in QoL among former smokers than among those who continue to smoke. Morbidity is higher in former smokers than in never smokers, but in some subgroups, morbidity among former smokers can approach that of never smokers, such as among those with lower levels of addiction at the time of cessation.

A causal link between smoking cessation and a decrease in general morbidity is supported by the biologic plausibility of the relationship. Many well-supported mechanisms link smoking cessation to improvements in more specific measures of health, such as disease-specific outcomes, thus underscoring the certainty that those who quit smoking will have lower rates of morbidity.

The health benefits of smoking cessation on all-cause mortality have been covered extensively in previous Surgeon General’s reports. The evidence that has accumulated since the 1990 Surgeon General’s report affirms that smoking cessation at any age reduces the risk of premature death from a smoking-caused illness.

Cigarette smoking generates substantial smoking-attributable healthcare expenditures and lost productivity. These expenditures affect the smoker specifically and society generally. The evidence from economic evaluations that focus on the cost-effectiveness of smoking cessation interventions demonstrates that such interventions are cost-effective from various perspectives. Taken together, the scientific evidence on the health and cost benefits of smoking cessation interventions indicates that these interventions should be implemented as widely as possible throughout the healthcare system and supported more broadly by population-level tobacco control measures.

Conclusions

1. The evidence is sufficient to infer that smoking cessation improves well-being, including higher quality of life and improved health status.
2. The evidence is sufficient to infer that smoking cessation reduces mortality and increases the lifespan.
3. The evidence is sufficient to infer that smoking exacts a high cost for smokers, healthcare systems, and society.
4. The evidence is sufficient to infer that smoking cessation interventions are cost-effective.

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