Effectiveness, Cost-effectiveness, and Cost-Utility of a Digital Smoking Cessation Intervention for Cancer Survivors: Health Economic Evaluation and Outcomes of a Pragmatic Randomized Controlled Trial

Abstract

Background: Smoking cessation (SC) interventions may contribute to better treatment outcomes and the general well-being of cancer survivors.

Objective: This study aims to evaluate the effectiveness, cost-effectiveness, and cost-utility of a digital interactive SC intervention compared with a noninteractive web-based information brochure for cancer survivors.

Methods: A health economic evaluation alongside a pragmatic 2-arm parallel-group randomized controlled trial was conducted with follow-ups at 3, 6, and 12 months. The study was conducted in the Netherlands over the internet from November 2016 to September 2019. The participants were Dutch adult smoking cancer survivors with the intention to quit smoking. In total, 165 participants were included and analyzed: 83 (50.3%) in the MyCourse group and 82 (49.7%) in the control group. In the intervention group, participants had access to a newly developed, digital, minimally guided SC intervention (MyCourse-Quit Smoking). Control group participants received a noninteractive web-based information brochure on SC. Both groups received unrestricted access to usual care. The primary outcome was self-reported 7-day smoking abstinence at the 6-month follow-up. Secondary outcomes were quality-adjusted life years gained, number of cigarettes smoked, nicotine dependence, and treatment satisfaction. For the health economic evaluation, intervention costs, health care costs, and costs stemming from productivity losses were assessed over a 12-month horizon.

Results: At the 6-month follow-up, the quit rates were 28% (23/83) and 26% (21/82) in the MyCourse and control groups, respectively (odds ratio 0.47, 95% CI 0.03-7.86; P=.60). In both groups, nicotine dependence scores were reduced at 12 months, and the number of smoked cigarettes was reduced by approximately half. The number of cigarettes decreased more over time, and the MyCourse group demonstrated a significantly greater reduction at the 12-month follow-up (incidence rate ratio 0.87; 95% CI 0.76-1.00; P=.04). Intervention costs were estimated at US $193 per participant for the MyCourse group and US $74 for the control group. The mean per-participant societal costs were US $25,329 (SD US $29,137) and US $21,836 (SD US $25,792), respectively. In the cost-utility analysis, MyCourse was not preferred over the control group from a societal perspective. With smoking behavior as the outcome, the MyCourse group led to marginally better results per reduced pack-year against higher societal costs, with a mean incremental cost-effectiveness ratio of US $52,067 (95% CI US $32,515-US $81,346).

Conclusions: At 6 months, there was no evidence of a differential effect on cessation rates; in both groups, approximately a quarter of the cancer survivors quit smoking and their number of cigarettes smoked was reduced by half. At 12 months, the MyCourse intervention led to a greater reduction in the number of smoked cigarettes, albeit at higher costs than for the control group. No evidence was found for a differential effect on quality-adjusted life years.

Trial registration: The Netherlands Trial Register NTR6011; https://www.trialregister.nl/trial/5434.

International registered report identifier (irrid): RR2-10.1186/s12885-018-4206-z.

Keywords: cancer survivors; cost-effectiveness; eHealth; effectiveness; smoking cessation.

Figure 1

Intervention flowchart (adapted from Mujcic et al [21]).

Figure 2

CONSORT (Consolidated Standards of Reporting Trials) flowchart. RCT: randomized controlled trial.

Figure 3

Percentage of quitters in both groups at baseline and during the course of the study. A total of 3 participants quitted smoking between screening and completing the baseline questionnaire.

Figure 4

Mean number of cigarettes smoked in both groups at baseline and during the course of the study, including SEs. Error bars show SEs of the mean.

Figure 5

Cost-effectiveness planes and cost-effectiveness acceptability curves in US $. Each quadrant in the cost-effectiveness planes represents a different association between the incremental costs (y-axis) and the incremental effects (x-axis) of the MyCourse group compared with the control group. When incremental cost-effectiveness ratios (ICERs) fall in the upper-right quadrant, this represents more effect at higher costs. When ICERs fall in the upper-left quadrant, this represents less effect at higher costs, meaning the MyCourse group is dominated by the control group. ICERs in the lower-right quadrant represent more effect at lower costs: the dominant quadrant. ICERs in the lower-left quadrant represent less effect at lower costs. QALY: quality-adjusted life year; WTP: willingness to pay.