CHICAGO — An intensive smoking cessation intervention that starts while patients are hospitalized for an acute cardiac event is not merely highly cost effective, it is actually cost saving, Robyn Kondrack, Pharm.D., reported at the annual meeting of the American College of Cardiology.
Indeed, the mean cost-effectiveness ratio of providing a 3-month intensive smoking cessation intervention (SCI) to hospitalized smokers in a 209-patient randomized controlled trial was $1,443 per year of life gained, according to Dr. Kondrack of Creighton University, Omaha, Neb.
The total direct cost of medical care during 5 years of prospective follow-up in the SCI arm of the study was $872,376, including nearly $250,000 for the smoking cessation program itself, compared with $1,025,000 in patients randomized to usual care. The major driver of the more than $150,000 in cost savings in the SCI group was their reduced hospital costs over the 5-year period.
Dr. Kondrack's cost analysis was a follow-up to last year's initial report on the Creighton University randomized trial, which showed a 2-year all-cause mortality of 2.8% in the intensive SCI group compared with 12.0% in the usual care controls, a 77% relative risk reduction. Twenty-five patients in the SCI group were hospitalized during the first 2 years of follow-up, as were 41 controls, for a 44% relative risk reduction (Chest 2007;131:446-52).
The investigators said although the 16 prior randomized controlled trials of SCIs in hospitalized smokers published since 1985 had clearly established that such programs result in higher smoking abstinence rates than usual care, theirs was the first to demonstrate reduced morbidity and mortality in response to an SCI.
All participants in the Nebraska study were smokers hospitalized in a coronary care unit for an acute cardiac syndrome or acute decompensated heart failure. All received a 30-minute inpatient smoking cessation counseling session; the usual-care group also received printed educational materials before discharge.
The structured SCI consisted of a minimum of 12 weekly behavior modification sessions with a counselor who has expertise in nicotine addiction, along with individualized pharmacotherapy—bupropion (Wellbutrin) and/or nicotine replacement therapy—provided at no cost to the patient. Seventy-five percent of patients in the SCI utilized the adjuvant pharmacotherapy, as did just 17% in the usual care group.
The biochemically confirmed continuous smoking abstinence rate at 2 years was 33% in the SCI group, compared with 9% with usual care.
The number-needed-to-treat using the intensive SCI to prevent one additional death during 2 years was 11. The results suggest smoking cessation may be the most effective secondary prevention measure available to smokers with cardiovascular disease—more effective than statins, antiplatelet agents, or other drugs considered standard therapy.
In an ACP Journal Club commentary on the Creighton trial, Dr. Charles J. Bentz of Providence St. Vincent Medical Center, in Portland, Ore., called it a landmark study (ACP J Club 2007;147:3).
Only 14 states cover outpatient smoking cessation counseling for all Medicaid recipients, and only Oregon covers all forms of counseling and medication, he noted, adding that the study “should serve as a call to all payers, public and private, to reevaluate their coverage for intensive tobacco cessation interventions.”
Dr. Kondrack noted that roughly three-quarters of the cost of the intensive SCI program was for personnel, with another 18% going for office and pharmaceutical supplies.