Cost-Effectiveness of Smoking Cessation Interventions in the Lung Cancer Screening Setting: A Simulation Study

Abstract

Background: Guidelines recommend offering cessation interventions to smokers eligible for lung cancer screening, but there is little data comparing specific cessation approaches in this setting. We compared the benefits and costs of different smoking cessation interventions to help screening programs select specific cessation approaches.

Methods: We conducted a societal-perspective cost-effectiveness analysis using a Cancer Intervention and Surveillance Modeling Network model simulating individuals born in 1960 over their lifetimes. Model inputs were derived from Medicare, national cancer registries, published studies, and micro-costing of cessation interventions. We modeled annual lung cancer screening following 2014 US Preventive Services Task Force guidelines plus cessation interventions offered to current smokers at first screen, including pharmacotherapy only or pharmacotherapy with electronic and/or web-based, telephone, individual, or group counseling. Outcomes included lung cancer cases and deaths, life-years saved, quality-adjusted life-years (QALYs) saved, costs, and incremental cost-effectiveness ratios.

Results: Compared with screening alone, all cessation interventions decreased cases of and deaths from lung cancer. Compared incrementally, efficient cessation strategies included pharmacotherapy with either web-based cessation ($555 per QALY), telephone counseling ($7562 per QALY), or individual counseling ($35 531 per QALY). Cessation interventions continued to have costs per QALY well below accepted willingness to pay thresholds even with the lowest intervention effects and was more cost-effective in cohorts with higher smoking prevalence.

Conclusion: All smoking cessation interventions delivered with lung cancer screening are likely to provide benefits at reasonable costs. Because the differences between approaches were small, the choice of intervention should be guided by practical concerns such as staff training and availability.

Figure 1.

Costs per QALYs gained from adding smoking cessation interventions to lung cancer screening. Strategies are in ascending order of costs: Sc Alone = screening plus no cessation; Sc + Pharm = screening plus pharmacotherapy; Sc + Web = screening plus electronic/web-based plus pharmacotherapy; Sc + Phone = screening plus phone plus pharmacotherapy; Sc + Group = screening plus group counseling plus pharmacotherapy; Sc + Indiv = screening plus individual counseling plus pharmacotherapy. Efficient strategies were those that yielded an increasing cost-to-benefit ratio; all other strategies are dominated. QALY = quality-adjusted life-years.

Figure 2.

Effects of 1-way and multi-way sensitivity analyses on costs per QALY of screening plus telephone counseling and pharmacotherapy compared with screening alone. The vertical line represents the costs per QALY of the base case screening plus telephone counseling and pharmacotherapy compared with screening alone with screening coverage set to 15% from column 3, Table 3 ($1019/QALY). The sensitivity analysis from the top down are as follows: ideal case—screening plus telephone counseling and pharmacotherapy at the lowest costs ($375) and highest effects (relative risk [RR] = 2.44) compared with screening alone with screening coverage set to 100% in the 1960s birth cohort; 1950s birth cohort—screening plus telephone counseling and pharmacotherapy among screen-eligible individuals in the 1950s birth cohort with base case costs and effects and screening coverage set to 15%; best/worst case—screening plus telephone counseling and pharmacotherapy at the highest costs ($603) and lowest effects (RR = 1.98) compared with screening alone and at the lowest costs ($375) and highest effects (RR = 2.44) compared with screening alone with screening coverage set to 15% in the 1960s birth cohort; increased screening coverage—screening plus telephone counseling and pharmacotherapy with base case costs and effects and screening coverage set to 100% in the 1960s birth cohort; highest and lowest costs—screening plus telephone counseling and pharmacotherapy with highest ($603) and lowest costs ($375), base case effects, and screening coverage set to 15% in the 1960s birth cohort; highest and lowest effects—screening plus telephone counseling and pharmacotherapy with highest (RR = 2.44) and lowest (RR = 1.98) effects, base case costs, and screening coverage set to 15% in the 1960s birth cohort. See also Supplementary Table 3, available online. QALY = quality-adjusted life-years.