3081 — Cost-effectiveness of integrating tobacco cessation into PTSD treatment

Barnett PG, Health Economics Resource Center, Veterans Affairs Palo Alto Health Care System; Jeffers A, Department of Management Science and Engineering, Stanford University; Smith MW, Truven Health Analytics; Chow BK, Cooperative Studies Program Coordinating Center, Veterans Affairs Palo Alto Health Care System; McFall M, Veterans Affairs Puget Sound Health Care System; Saxon A, Department of Psychiatry and Behavioral Sciences, University of Washington;

Objectives:
We examined the cost-effectiveness of smoking cessation integrated with treatment for Post-Traumatic Stress Disorder (PTSD).

Methods:
Smoking veterans receiving care for PTSD (N = 943) were randomized to care integrated with smoking cessation versus referral to a smoking cessation clinic. Smoking cessation services, health care cost and utilization, quality of life, and biochemically-verified abstinence from cigarettes were assessed over 18-months of follow-up. Clinical outcomes were combined with literature on changes in smoking status and the effect of smoking on health care cost, mortality, and quality of life in a Markov model of cost-effectiveness over a lifetime horizon. We discounted cost and outcomes at 3% per year and report costs in 2010 U.S. dollars.

Results:
Smoking cessation services had a mean cost of $1,286 for those randomized to integrated care compared to $551 for those receiving standard care (p < 0.001). There were no significant differences in the cost of mental health services or other care. Prolonged biochemically verified abstinence was observed in 8.9% of those randomized to integrated care and 4.5% of those randomized to standard care (p = 0.004). The model projected that Integrated Care added $836 in lifetime cost and generated 0.0259 Quality Adjusted Life Years (QALYs), resulting in an incremental cost-effectiveness ratio of $32,257 per QALY. It was 86.0% likely to be cost-effective compared to a threshold of $100,000/QALY.

Implications:
Smoking cessation integrated with treatment for PTSD was cost-effective, within a broad confidence region, but less cost-effective than most other smoking cessation programs reported in the literature.

Impacts:
Veterans with PTSD and other serious mental illness have greater incidence of smoking and greater smoking related mortality than Veterans without these illnesses. Quit rates for individuals with mental illness are lower than in other smokers and more resources may be needed for successful treatment. The incremental value of quitting is attenuated by the lower quality of life and higher non-smoking mortality rates in persons with mental illness. Although smoking interventions may be less cost-effective in PTSD and other serious mental illnesses, they deliver sufficient value to merit implementation.