Cost-Effectiveness Analysis of Smoking Cessation Interventions in the United Kingdom Accounting for Major Neuropsychiatric Adverse Events

Abstract

Smoking is a leading cause of death worldwide. Cessation aids include varenicline, bupropion, nicotine replacement therapy (NRT), and e-cigarettes at various doses (low, standard and high) and used alone or in combination with each other. Previous cost-effectiveness analyses have not fully accounted for adverse effects nor compared all cessation aids. The objective was to determine the relative cost-effectiveness of cessation aids in the United Kingdom. Methods: An established Markov cohort model was adapted to incorporate health outcomes and costs due to depression and self-harm associated with cessation aids, alongside other health events. Relative efficacy in terms of abstinence and major adverse neuropsychiatric events was informed by a systematic review and network meta-analysis. Base case results are reported for UK-licensed interventions only. Two sensitivity analyses are reported, one including unlicensed interventions and another comparing all cessation aids but removing the impact of depression and self-harm. The sensitivity of conclusions to model inputs was assessed by calculating the expected value of partial perfect information. Results: When limited to UK-licensed interventions, varenicline standard-dose and NRT standard-dose were most costeffective. Including unlicensed interventions, e-cigarette low-dose appeared most cost-effective followed by varenicline standard-dose 1 bupropion standard-dose combined. When the impact of depression and self-harm was excluded, varenicline standard-dose 1 NRT standard-dose was most cost-effective, followed by varenicline low-dose 1 NRT standard-dose. Conclusion: Although found to be most cost-effective, combined therapy is currently unlicensed in the United Kingdom and the safety of e-cigarettes remains uncertain. The value-of-information analysis suggested researchers should continue to investigate the long-term effectiveness and safety outcomes of e-cigarettes in studies with active comparators.

Incremental net monetary benefit of using varenicline for smoking cessation: A systematic review and meta‐analysis of economic evaluation studies

“…Of the 1451 identified studies, 18 studies [17, 18, 21, 23, 25–28, 56–65] were eligible for the meta‐analysis (Figure 1), including 48 comparisons; varenicline versus bupropion (N = 14, C = 15) [17, 18, 21, 23, 25–28, 56, 57, 59, 60, 63, 64], varenicline versus NRT (N = 13, C = 17) [17, 18, 21, 25–28, 56, 58–60, 63, 65], varenicline versus behavioural support interventions alone (N = 5, C = 6) [17, 26, 59, 62, 64] and varenicline versus unaided cessation (N = 10, C = 11) [17, 18, 21, 23, 25, 26, 28, 56, 60, 61].…”

“…Of the complete set of 18 studies, three of them adhered to scenario 4, whereas the remaining 15 studies followed scenario 5. Sixteen studies [17,18,21,23,25,27,28,[56][57][58][60][61][62][63][64][65] were performed in HICs, whereas two studies [26,59] were conducted in LMICs. The majority of studies [17,18,21,23,25,28,[56][57][58][59][60][63][64][65] (72.22%) used the benefits of smoking cessation on outcomes (BENESCO) model, although others [26,27,61,62] used alternative models such as a discrete-event simulation or the European study on quantifying utility of investment in protection from tobacco model (EQUIPTMOD).…”

“…In the majority of studies, reporting and dissemination bias, as well as bias related to internal consistency, were rated as unclear. Seven studies classified as low risk of bias (38.89%) [18,21,23,26,59,60,63], nine studies classified as moderate risk of bias (50.00%) [17,25,27,28,57,58,61,64,65] and two studies classified as high risk of bias (11.11%) (Appendix S6) [56,62].…”

Comparative clinical effectiveness and safety of tobacco cessation pharmacotherapies and electronic cigarettes: a systematic review and network meta‐analysis of randomized controlled trials

“…The inclusion of electronic cigarettes and specification of covariates were decided following the submission of our PROSPERO record and protocol manuscript for peer review. The findings of our analyses of safety data from observational studies with control groups [ 35 ] and our cost‐effectiveness analyses [ 36 ] are reported elsewhere. We were unable to include and analyse craving and withdrawal data, as these were rarely reported among the included studies and were measured using a variety of measures and scales, so evidence synthesis was impossible.…”

A digital solution to streamline access to smoking cessation interventions in England; findings from a primary care pilot (STOPNOW study)

“…As the time between the decision to quit by a smoker and access to behavioural support, pharmacotherapy or NRT on the NHS is protracted and could take days in some instances, it is desirable to explore the use of an IT enabled primary care led pathway that would give patients who smoke the option to make an asynchronous formal request for treatment without the need to make a visit to their GP practice or a smoking cessation provider in the community setting. This arrangement could facilitate speedier access to NRT, pharmacotherapy and POM via electronic prescription service (EPS) and may increase patient motivation to stop smoking and successful quit attempts whilst reducing costs and pressures on general practice [ 31 , 32 ].…”