Smoking cessation with nicotine replacement therapy to reduce healthcare costs

Among the approaches to avoiding illness and thus illness costs, reducing the smoking rate is of outstanding medical and economic importance. Smoking represents the most significant avoidable health risk, both quantitatively and qualitatively, for a variety of serious diseases, including cancer, cardiovascular diseases and respiratory diseases. There are around 5 million victims of tobacco consumption every year worldwide, while the corresponding figures for Germany are 110,000 to 140,000 people per year. The costs for the treatment of tobacco-related diseases in Germany amounted to 7.5 billion euros in 2003, the total costs attributable to tobacco amounted to 21 billion euros and a total of 1.6 million years of life lost.

>> Reducing smoking prevalence is therefore an effective approach to reducing health risks and the resulting high medical and treatment costs. Effective, evidence-based methods are now available to support people in quitting smoking. Among drug therapies, nicotine replacement therapy (NET) plays an important role nationally and internationally; it doubles the chance of being permanently smoke-free.
Knowledge about the importance and consequences of smoking developed only slowly. For many decades, the dimension of smoking was tolerated and not questioned in all countries. A process of rethinking began in the last half of the 20th century, particularly in the Anglo-American region. As the financing problems of social systems worsened, innovative approaches to avoiding illness and thus the costs of illness were discussed and put into practice, especially in Great Britain. These can also be seen as groundbreaking for Germany.
This article will therefore first address developments in Great Britain. As part of the National Health Service (NHS), care structures have been established, which are based not least on studies on the cost-effectiveness of NET by the National Institute for Clinical Excellence (NICE). In the second part, the potential of nicotine replacement therapy for use in smoking cessation in Germany and especially in chronic diseases will be examined based on new study data based on two current pharmacoeconomic studies.
The British health project 'Smoking Kills'
The beginnings: The 'White Paper on Tobacco' 1998
The British health project developed on the basis of the 'White Paper on Tobacco' published in 1998, which was unambiguous in its core message: 'Smoking kills'. This White Paper, presented by the UK Department of Health, was based on the following considerations: Smoking is the single largest cause of preventable disease and premature death. Smoking kills more than 120,000 people in the UK every year - more than 13 people an hour. 84 % of lung carcinomas, 83 % of chronic obstructive pulmonary disease (COPD) are caused by smoking. At the same time, smoking is a problem for social classes. It is primarily the disadvantaged groups that are particularly affected. Overall, the annual smoking-attributable costs of the British health system, NHS (doctor, medication, treatment costs) were estimated at 1.7 billion pounds.
In general, the British health system pursued the goals of improving the health of the population as a whole through a longer and healthier life and reducing disadvantages in the social and health area. In order to achieve these goals, the British government set the following target criteria, projected for 2010.
• Adults: Reducing the prevalence of smoking
28 % to 24 %,
• Children and young people: reduction from 13 % to 9 % and
• Pregnant women: reduction from 23 % to 15 %.

These target criteria should be achieved by increasing the tobacco tax, restricting tobacco advertising, and banning smoking in public institutions, restaurants and pubs. However, the focus was on establishing a smoking cessation health service as an integral part of the NHS. An investment volume of 60 million pounds was planned for this alone for the first three years.
The 'NHS Stop Smoking Service' was designed as a nationwide measure. The smoking cessation measures were implemented through a step-by-step, step-by-step intervention. General practitioners were asked to carry out a so-called short intervention for smoking patients. Pharmacotherapy should also be initiated with evidence-based and cost-effective therapeutics, such as nicotine replacement therapy (NET) (see box). If necessary, those wishing to quit could be referred to qualified focus centers where additional advice, support and/or behavioral therapy interventions were offered. In addition, the availability of nicotine replacement should be improved. The low-dose application forms were exempted from the pharmacy requirement.
The costs for this service are borne by the NHS (for developments see Table 1). The cost of pharmacotherapy when prescribed by a doctor is also part of the NHS care package. An additional 50 million were earmarked for a public relations campaign in the first three years. In order to closely monitor the implementation of the measures and their success, the entire project was meticulously documented.

Positive assessment of a British decade of NHS Stop
Smoking Services 1998 - 2008
In the ten years since 'Smoking Kills' was published, the prevalence of smoking in England has been reduced from 28 % to 22 %. All major goals were achieved.
The number of exit attempts increased over the course of the project. In 2007/08 there were over 680,000 people. 52 % remained smoke-free after 4 weeks, so the expenditure for each ex-smoker was approximately £173 (see Table 1). In the period from April to September 2008, a total of 710,940 nicotine replacement products were prescribed in England. The net cost over this period was £14.7 million for NRT products - for the medication totaling £27.6 million. But the level of use in the area of self-medication is also significant. It even exceeds the prescription range by 1.5 times.
Despite the successes described, a recalculation of tobacco-related costs and the burden of smoking on the English NHS for 2006/07 still resulted in a total of £2.7 million. A national alliance is now calling for efforts to step up 'Smoking Kills', the ambitious target for 2015: a smoking rate of 11 % in the adult population.
The topic of 'smoking' in health policy
Germany's landscape - status quo
Tobacco cessation in the German healthcare system
The proportion of smokers in the German population is approx. 27 %; a reduction has recently not been observed. The current circumstances are therefore similar to those at the start of the 'Smoking Kills' project in Great Britain. However, there is currently no recommendation on how to proceed that is structured analogously to the British model. The problem of reducing tobacco consumption is formulated in the German healthcare system as a behavioral preventive measure. Therefore, the draft national action program focuses on increasing the offerings and increasing the motivation of those involved in the health system without defining a financial investment.
At present, the participation fees for group courses on behavioral therapy for smoking cessation are partially reimbursed by the statutory health insurance providers upon the individual request of the participant on the basis of Section 20 of the Federal Social Law. In 2006, 11,800 people wanting to quit took advantage of this. There is no medication available to promote smoking cessation. This is justified by the legislature's regulation regarding the reimbursement of medicines for the treatment of tobacco addiction in accordance with Section 34 SGB V: “Medicines whose use is intended to increase the quality of life are also excluded from the supply. In particular, medicines “… for smoking cessation…” are excluded. The widely proven health benefits of quitting smoking are thereby called into question and the presence of an addiction in a significant proportion of smokers is not taken into account. In a more recent report, IQWiG also came to the conclusion that NETs should be taken into account when smoking cessation. A current study, the Eurobarometer, reflects the clear differences in the attitudes of British and German smokers to quitting (see Figure 2). The total tobacco-attributable costs for Germany in 2003 were calculated at 21 billion euros and 1.6 million years of life lost. The state's tobacco tax revenue amounted to 13.6 billion euros in 2008.
Cost-effectiveness ratio of nicotine replacement therapy
for smoking cessation
Two studies on the benefits and cost-effectiveness of NET in smoking cessation were conducted by Prof. Dr. Jürgen Wasem, University of Duisburg-Essen, carried out in the past two years, commissioned by the 'Smoking Cessation Initiative' by a working group in the Federal Association of Drug Manufacturers (BAH). The common goal of the studies was to determine the years of life gained and the costs with NET compared to smoking cessation therapy with placebo NET. The studies differed in their evaluation perspective. In the first study, statements were made with regard to the entire population of smokers, while the second study referred to groups of smokers with defined previous illnesses.
The basic model approach chosen was the same in both cases and immediately followed the following thought pattern:
The starting point are two scientifically evident facts:
1. Smoking cessation with NET is therapeutically more successful
as smoking cessation with placebo treatment.
2. Smokers have higher health care costs than
Non-smoker.
If these two premises hold, it follows that
3. Smoking cessation with NET leads to a reduction in the
resulting health costs associated with smoking.

The extent to which NET is cost-effective depends on the therapy costs and even more so on the specific success rates as well as the relevant healthcare costs and had to be explained as part of the studies. The study results are based on the epidemiological data on the prevalence of tobacco-attributable diseases, the scientific findings on the health benefits of smoking cessation and the data on the efficacy and effectiveness of the use of drugs for nicotine replacement therapy (NET).
The 1st study (2007):
Benefits and cost-effectiveness of NET for smoking prevention
cessation in the overall population of smokers
According to expert estimates, it can be assumed that 5 million people in Germany would undergo smoking cessation therapy. For the analysis, a synthetic group of 5 million smokers was formed, all of whom were either attempting to quit smoking without smoking cessation therapy (strategy A), or attempting to quit smoking with NET (strategy B). The group of 5 million smokers was composed according to the age and gender distribution of smokers according to the 2005 microcensus. The one-time attempt to quit smoking made by everyone is either successful or unsuccessful. If the attempt to quit smoking is unsuccessful, the smoker remains in the group of smokers; if he is successful, he switches to the group of ex-smokers.
The modeling approach is represented by the following decision tree diagram:
The two strategies A and B differ in the probability that the attempt to quit smoking will be successful. Based on current knowledge, it can be assumed that in an attempt to quit smoking with placebo therapy (strategy A), approximately 10 % of the quit attempts are successful; In contrast, it is assumed that an attempt to quit smoking with NET (strategy B) has approximately twice the probability of success. Since, according to the relevant Cochrane review, there are no significant differences between the different forms of nicotine cessation therapies, no further differentiation was made. It was also assumed that the success rates were identical in all age and gender groups. This means that in strategy A, after attempting to quit smoking, 90 % of the people still belong to the group of smokers and 10 % to the group of ex-smokers; In contrast, in strategy B, after attempting to quit smoking, 83 % of the people still belong to the group of smokers and 17 % to the group of ex-smokers.
Results of the model calculations study 1
The results of the model calculations were qualitatively described and summarized. First of all, it can be stated that due to the higher probability of success of tobacco withdrawal using NET and the use of these medications, a large number of additional years of life can be gained, both according to the concept of years of life gained (LYG) and according to the concept of quality-adjusted life years (QALY). In addition to the years of life saved, the greater effectiveness of nicotine replacement therapy compared to non-medicinal tobacco withdrawal is also reflected in an improved health-related quality of life during the remaining life of smokers who have successfully given up smoking. This is reflected in the higher number of QALYs.
Since more people succeed in becoming non-smokers with the help of NET than without it, its use leads to a reduction in the number and severity of smoking-related illnesses. It is also to be expected that, in addition to the direct medical costs that arise from illnesses attributable to tobacco, indirect effects such as loss of productivity and absences from work can also be reduced by NET.
Cost-effectiveness of nicotine replacement therapy
In the case of NET medications available without a prescription, the therapy costs are limited to the costs for these medications, as their effectiveness has been proven independently of other supportive measures. Regardless of whether cost per LYG or cost per QALY is used as a criterion, in any case NET proves to be a cost-effective option for smoking cessation and at the same time a cost-effective use of health care resources to gain additional years and quality of life.
The 2nd study (2008):
Benefits and cost-effectiveness of NET for smoking cessation in smokers with defined previous illnesses
The second study is a follow-up project to the study described. The basic approach and model structure are structured in an analogous manner; the proven influence of smoking on the emergence and development of lung (COPD) and heart/circulatory diseases was newly included as the basis for this study Diabetes (DMT2). Against this background, smoking cessation is particularly recommended for secondary and tertiary prevention in those who are already ill. Table 3 provides an insight into the quantitative partial results of this study.
The new study results also show that quitting smoking with the aforementioned pre-existing conditions is not only medically necessary, but also cost-effective from a statutory health insurance perspective. Financial resources spent in this area on medication-based smoking cessation could be overcompensated by savings in follow-up costs within a time horizon of around three years.
Discussion of the study results Study 2
In order to ensure the robustness of the statements, several sensitivity analyzes were carried out and, last but not least, the assumptions were chosen to be very restrictive. This can be illustrated as an example using the problem of passive smoking, the consideration of which would further improve the cost-effectiveness of NET, but has been completely excluded here. Furthermore, when estimating future health care costs, the cost development was not updated in the sense of an innovation component, although the disproportionate use of health care by smokers tends to underestimate the cost effectiveness.
Intangible effects could not be included in the model calculations presented here, but they play an important role in the present context. As shown, the reduction in suffering and pain associated with the prevention of disease through successful tobacco withdrawal is to be attributed to nicotine replacement therapy to a greater extent than to a non-drug strategy.
Health policy conclusions
and outlook
Both the medical and the health economic perspective raise the question of whether the treatment of tobacco dependence should be given greater importance in the context of public health promotion and whether greater emphasis should be placed on the effectiveness of nicotine replacement therapy. This is confirmed by the experimentally determined cost-effectiveness, even under the conditions of NET medication that is free of charge for the user. There is currently the impression that the positive medical and health economic effects shown in the present model are not sufficiently realized in practice.
The results of the present study also indicate that the categorization as a lifestyle preparation does not appear appropriate in view of the social benefits of NET. However, a change in social law could send an important signal to specialist circles and patients, especially for the treatment of smokers with defined previous illnesses, since the influence of smoking on the emergence and development of lung and cardiovascular diseases and diabetes is evident and well documented is. Against this background, smoking cessation is recommended for secondary and tertiary prevention for those who are already ill in the areas mentioned. The results of the second study carried out show that quitting smoking with the aforementioned pre-existing conditions is also cost-effective from the point of view of the statutory health insurance. Financial resources spent in this area on medication-based smoking cessation can be overcompensated by savings in follow-up costs within a time horizon of around three years. <<