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Meta-Analysis
. 2017 Sep 12;9(9):CD004305.
doi: 10.1002/14651858.CD004305.pub5.

Healthcare financing systems for increasing the use of tobacco dependence treatment

Floor A van den Brand  1 , Gera E Nagelhout, Ayalu A Reda, Bjorn Winkens, Silvia M A A Evers, Daniel Kotz, Onno Cp van Schayck
Affiliations
Meta-Analysis

Healthcare financing systems for increasing the use of tobacco dependence treatment

Floor A van den Brand et al. Cochrane Database Syst Rev. .

Abstract

Background: Tobacco smoking is the leading preventable cause of death worldwide, which makes it essential to stimulate smoking cessation. The financial cost of smoking cessation treatment can act as a barrier to those seeking support. We hypothesised that provision of financial assistance for people trying to quit smoking, or reimbursement of their care providers, could lead to an increased rate of successful quit attempts. This is an update of the original 2005 review.

Objectives: The primary objective of this review was to assess the impact of reducing the costs for tobacco smokers or healthcare providers for using or providing smoking cessation treatment through healthcare financing interventions on abstinence from smoking. The secondary objectives were to examine the effects of different levels of financial support on the use or prescription of smoking cessation treatment, or both, and on the number of smokers making a quit attempt (quitting smoking for at least 24 hours). We also assessed the cost effectiveness of different financial interventions, and analysed the costs per additional quitter, or per quality-adjusted life year (QALY) gained.

Search methods: We searched the Cochrane Tobacco Addiction Group Specialised Register in September 2016.

Selection criteria: We considered randomised controlled trials (RCTs), controlled trials and interrupted time series studies involving financial benefit interventions to smokers or their healthcare providers, or both.

Data collection and analysis: Two reviewers independently extracted data and assessed the quality of the included studies. We calculated risk ratios (RR) for individual studies on an intention-to-treat basis and performed meta-analysis using a random-effects model.

Main results: In the current update, we have added six new relevant studies, resulting in a total of 17 studies included in this review involving financial interventions directed at smokers or healthcare providers, or both.Full financial interventions directed at smokers had a favourable effect on abstinence at six months or longer when compared to no intervention (RR 1.77, 95% CI 1.37 to 2.28, I² = 33%, 9333 participants). There was no evidence that full coverage interventions increased smoking abstinence compared to partial coverage interventions (RR 1.02, 95% CI 0.71 to 1.48, I² = 64%, 5914 participants), but partial coverage interventions were more effective in increasing abstinence than no intervention (RR 1.27 95% CI 1.02 to 1.59, I² = 21%, 7108 participants). The economic evaluation showed costs per additional quitter ranging from USD 97 to USD 7646 for the comparison of full coverage with partial or no coverage.There was no clear evidence of an effect on smoking cessation when we pooled two trials of financial incentives directed at healthcare providers (RR 1.16, CI 0.98 to 1.37, I² = 0%, 2311 participants).Full financial interventions increased the number of participants making a quit attempt when compared to no interventions (RR 1.11, 95% CI 1.04 to 1.17, I² = 15%, 9065 participants). There was insufficient evidence to show whether partial financial interventions increased quit attempts compared to no interventions (RR 1.13, 95% CI 0.98 to 1.31, I² = 88%, 6944 participants).Full financial interventions increased the use of smoking cessation treatment compared to no interventions with regard to various pharmacological and behavioural treatments: nicotine replacement therapy (NRT): RR 1.79, 95% CI 1.54 to 2.09, I² = 35%, 9455 participants; bupropion: RR 3.22, 95% CI 1.41 to 7.34, I² = 71%, 6321 participants; behavioural therapy: RR 1.77, 95% CI 1.19 to 2.65, I² = 75%, 9215 participants.There was evidence that partial coverage compared to no coverage reported a small positive effect on the use of bupropion (RR 1.15, 95% CI 1.03 to 1.29, I² = 0%, 6765 participants). Interventions directed at healthcare providers increased the use of behavioural therapy (RR 1.69, 95% CI 1.01 to 2.86, I² = 85%, 25820 participants), but not the use of NRT and/or bupropion (RR 0.94, 95% CI 0.76 to 1.18, I² = 6%, 2311 participants).We assessed the quality of the evidence for the main outcome, abstinence from smoking, as moderate. In most studies participants were not blinded to the different study arms and researchers were not blinded to the allocated interventions. Furthermore, there was not always sufficient information on attrition rates. We detected some imprecision but we judged this to be of minor consequence on the outcomes of this study.

Authors' conclusions: Full financial interventions directed at smokers when compared to no financial interventions increase the proportion of smokers who attempt to quit, use smoking cessation treatments, and succeed in quitting. There was no clear and consistent evidence of an effect on smoking cessation from financial incentives directed at healthcare providers. We are only moderately confident in the effect estimate because there was some risk of bias due to a lack of blinding in participants and researchers, and insufficient information on attrition rates.

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Conflict of interest statement

FB: none known GN: none known AAR: none known BW: none known SE: none known DK received an unrestricted grant from Pfizer in 2009 for an investigator‐initiated trial on the effectiveness of practice nurse counselling and varenicline for smoking cessation in primary care (Dutch Trial Register NTR3067) CPS and the lead author of the first version of this review conducted one of the trials included in the review (Kaper 2006)

Figures

1
1
Risk of bias summary: review authors' judgements about each risk of bias item for each included study
2
2
Prisma study flow diagram of studies included in most recent update of this review
1.1
1.1. Analysis
Comparison 1 Interventions directed at individuals: abstinence from smoking, Outcome 1 Full versus no financial coverage.
1.2
1.2. Analysis
Comparison 1 Interventions directed at individuals: abstinence from smoking, Outcome 2 Full versus partial financial coverage.
1.3
1.3. Analysis
Comparison 1 Interventions directed at individuals: abstinence from smoking, Outcome 3 Partial versus no financial coverage.
1.4
1.4. Analysis
Comparison 1 Interventions directed at individuals: abstinence from smoking, Outcome 4 Partial versus another partial coverage (at least 6 months CA).
2.1
2.1. Analysis
Comparison 2 Interventions directed at individuals: number of participants making a quit attempt for at least 24 h, Outcome 1 Full versus no financial coverage.
2.2
2.2. Analysis
Comparison 2 Interventions directed at individuals: number of participants making a quit attempt for at least 24 h, Outcome 2 Full versus partial financial coverage.
2.3
2.3. Analysis
Comparison 2 Interventions directed at individuals: number of participants making a quit attempt for at least 24 h, Outcome 3 Partial versus no financial coverage.
3.1
3.1. Analysis
Comparison 3 Interventions directed at individuals: use of smoking cessation treatment, Outcome 1 Full versus no financial coverage.
3.2
3.2. Analysis
Comparison 3 Interventions directed at individuals: use of smoking cessation treatment, Outcome 2 Full versus partial financial coverage.
3.3
3.3. Analysis
Comparison 3 Interventions directed at individuals: use of smoking cessation treatment, Outcome 3 Partial versus no financial coverage.
3.4
3.4. Analysis
Comparison 3 Interventions directed at individuals: use of smoking cessation treatment, Outcome 4 Partial versus partial financial coverage.
4.1
4.1. Analysis
Comparison 4 Interventions directed at healthcare providers, Outcome 1 Abstinence from smoking.
4.2
4.2. Analysis
Comparison 4 Interventions directed at healthcare providers, Outcome 2 Use of nicotine replacement therapy and/or bupropion.
4.3
4.3. Analysis
Comparison 4 Interventions directed at healthcare providers, Outcome 3 Use of behavioural interventions.
See this image and copyright information in PMC

Update of

References

References to studies included in this review

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References to ongoing studies

NCT00962988 {published data only}
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