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Jerry Cromwell, PhD; William J. Bartosch, MPA; Michael C. Fiore, MD, MPH; Victor Hasselblad, PhD; Timothy Baker, PhD

JAMA. 1997;278(21):1759-1766.

Abstract
Context.
—The Agency for Health Care Policy and Research (AHCPR) published the Smoking Cessation: Clinical Practice Guideline in 1996. Based on the results of meta-analyses and expert opinion, the guideline identifies efficacious interventions for primary care clinicians and smoking cessation specialty providers.

Objective.
—To determine the cost-effectiveness of clinical recommendations in AHCPR's guideline.

Design.
—The guideline's 15 recommended smoking cessation interventions were analyzed to determine their relative cost-effectiveness. Then, using decision probabilities, the interventions were combined into a global model of the guideline's overall cost-effectiveness.

Patients.
—The analysis assumes that primary care clinicians screen all presenting adults for smoking status and advise and motivate all smokers to quit during the course of a routine office visit or hospitalization. Smoking cessation interventions are provided to 75% of US smokers 18 years and older who are assumed to be willing to make a quit attempt during a year's time.

Intervention.
—Three counseling interventions for primary care clinicians and 2 counseling interventions for smoking cessation specialists were modeled with and without transdermal nicotine and nicotine gum.

Main Outcome Measure.
—Cost (1995 dollars) per life-year or quality-adjusted life-year (QALY) saved, at a discount of 3%.

Results.
—The guideline would cost $6.3 billion to implement in its first year. As a result, society could expect to gain 1.7 million new quitters at an average cost of $3779 per quitter, $2587 per life-year saved, and $1915 for every QALY saved. Costs per QALY saved ranged from $1108 to $4542, with more intensive interventions being more cost-effective. Group intensive cessation counseling exhibited the lowest cost per QALY saved, but only 5% of smokers appear willing to undertake this type of intervention.

Conclusions.
—Compared with other preventive interventions, smoking cessation is extremely cost-effective. The more intensive the intervention, the lower the cost per QALY saved, which suggests that greater spending on interventions yields more net benefit. While all these clinically delivered interventions seem a reasonable societal investment, those involving more intensive counseling and the nicotine patch as adjuvant therapy are particularly meritorious.

Author Affiliations
From Health Economics Research, Inc, Waltham, Mass (Dr Cromwell and Mr Bartosch); the Center for Tobacco Research and Intervention (Drs Fiore and Baker), Section of General Internal Medicine, Department of Medicine (Drs Fiore and Baker), Comprehensive Cancer Center (Dr Fiore), and Department of Psychology (Dr Baker), University of Wisconsin Medical School, Madison; and the Center for Health Policy Research and Education, Duke University, Durham, NC (Dr Hasselblad).

Footnotes
Since publication of the AHCPR Smoking Cessation Clinical Practice Guideline in April 1996, Dr Fiore has done consulting, received funding for clinical research studies, and/or spoken on behalf of GlaxoWellcome, SmithKline Beecham, and McNeil pharmaceutical companies. Dr Baker has done consulting, research, and/or speaking for SmithKline Beecham pharmaceutical company. Prior to 1994 (when work on the Guideline began), Drs Baker and Fiore had worked on clinical research studies funded in part by ALZA Corp, CIBA-Geigy Corp, Elan Pharmaceutical, Lederle Laboratories, Glaxo Wellcome, SmithKline Beecham, and Hoechst Marion Rousel Inc. Prior to 1994, Dr. Fiore had received honoraria for educational activities from CIBA-Geigy, Elan, Lederle, Marion Merrell Dow Inc, and Parke-Davis.

The statements contained in this article are solely those of the authors and do not necessarily reflect the views or opinions of the Agency for Health Care Policy and Research.

Reprints: Jerry Cromwell, PhD, Health Economics Research, Inc, 300 Fifth Ave, Sixth Floor, Waltham, MA 02154 (e-mail: jcromwell@her-cher.org).

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References
Circulation 2002;106:3373-3421.
FULL TEXT  

Cost-Effectiveness of Pharmacological Interventions for Smoking Cessation: a Literature Review and a Decision Analytic Analysis
Song et al.
Med Decis Making 2002;22:S26-S37.
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Optimal Allocation of Resources Across Four Interventions for Type 2 Diabetes
Earnshaw et al.
Med Decis Making 2002;22:S80-S91.
ABSTRACT  

Task Force #2--the cost of prevention: can we afford it? Can we afford not to do it?
Krumholz et al.
J Am Coll Cardiol 2002;40:603-615.
FULL TEXT  

Treatment of Tobacco Use and Dependence
Rigotti
NEJM 2002;346:506-512.
FULL TEXT  

A Simulation Model of Policies Directed at Treating Tobacco Use and Dependence
Levy and Friend
Med Decis Making 2002;22:6-17.
ABSTRACT  

The effect of risk factor reductions between 1981 and 1990 on coronary heart disease incidence, prevalence, mortality and cost
Goldman et al.
J Am Coll Cardiol 2001;38:1012-1017.
ABSTRACT | FULL TEXT  

Coverage of Smoking Cessation Treatment by Union Health and Welfare Funds
Barbeau et al.
AJPH 2001;91:1412-1415.
ABSTRACT | FULL TEXT  

Cost-effectiveness of a School-Based Tobacco-Use Prevention Program
Wang et al.
Arch Pediatr Adolesc Med 2001;155:1043-1050.
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Treating Nicotine Addiction . Not a Medical Problem?
BRITTON et al.
Am. J. Respir. Crit. Care Med. 2001;164:13-15.
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Izumi et al.
Int J Epidemiol 2001;30:616-621.
ABSTRACT | FULL TEXT  

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DAVIS et al.
Tobacco Control 2000;9:355-358.
FULL TEXT  

A survey of managed care strategies for pregnant smokers
Barker et al.
Tobacco Control 2000;9:46i-50.
ABSTRACT | FULL TEXT  

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Rigotti
JAMA 2000;284:741-749.
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The Tobacco Use and Dependence Clinical Practice G
JAMA 2000;283:3244-3254.
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Hu et al.
Tobacco Control 2000;9 :ii60-ii63.
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Elliott et al.
Arch Intern Med 2000;160:1277-1283.
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Prochazka
Chest 2000;117 :169S-175S.
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Lantz et al.
Tobacco Control 2000;9:47-63.
ABSTRACT | FULL TEXT  

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BARKER
Tobacco Control 2000;9:i1-1.
FULL TEXT  

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Hollis et al.
Tobacco Control 2000;9:i18-24.
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Designing tobacco control systems and cessation benefits in managed care: skill building workshop
Carlson et al.
Tobacco Control 2000;9:i25-29.
FULL TEXT  

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Solberg
Tobacco Control 2000;9:i37-41.
FULL TEXT  

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Seidenwurm et al.
Am. J. Neuroradiol. 2000;21:426-433.
ABSTRACT | FULL TEXT  

Guidelines in Pulmonary Medicine: A 25-Year Profile
Hackner et al.
Chest 1999;116:1046-1062.
ABSTRACT | FULL TEXT  

Four beliefs that may impede progress in the treatment of smoking
Hughes
Tobacco Control 1999;8:323-326.
ABSTRACT | FULL TEXT  

Adding Behavioral Therapy to Medication for Smoking Cessation
Deagle III et al.
JAMA 1999;281:1983-1985.
FULL TEXT  

Prevention of a First Stroke: A Review of Guidelines and a Multidisciplinary Consensus Statement From the National Stroke Association
Gorelick et al.
JAMA 1999;281:1112-1120.
ABSTRACT | FULL TEXT  

Perceived Risks of Heart Disease and Cancer Among Cigarette Smokers
Ayanian and Cleary
JAMA 1999;281:1019-1021.
ABSTRACT | FULL TEXT  

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Muennig et al.
NEJM 1999;340:773-779.
ABSTRACT | FULL TEXT  

Prevention and Medicare Costs
Russell
NEJM 1998;339:1158-1160.
FULL TEXT  

Use and Cost Effectiveness of Smoking-Cessation Services under Four Insurance Plans in a Health Maintenance Organization
Curry et al.
NEJM 1998;339:673-679.
ABSTRACT | FULL TEXT  

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Croghan et al.
JAMA 1998;279:836-837.
FULL TEXT  

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Koop et al.
JAMA 1998;279:550-552.
FULL TEXT  

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JWatch Women's Health 1998;1998:19-19.
FULL TEXT  

Patient Smoking Cessation Advice by Health Care Providers: The Role of Ethnicity, Socioeconomic Status, and Health
Houston et al.
AJPH 2005;95:1056-1061.
ABSTRACT | FULL TEXT  

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Ong and Glantz
AJPH 2005;95:969-975.
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Warner
AJPH 2005;95:976-984.
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