Objective In the Republic of Korea, nationwide government-supported Smoking Cessation Clinics have been operating in 253 public health centres since 2004, but the cost and effectiveness of the service have yet to be evaluated.
Methods The cost of the service (staff salary, medication, education and promotion and overhead) was calculated from the Smoking Cessation Clinic's 2009 financial report. The number of service users, self-reported 4-week and 6-month quit rates and the proportion of nicotine replacement therapy users were collected from the service's performance monitoring data. Long-term quit rate and life-years saved by quitting were estimated and used in addition to monitoring data to evaluate the effectiveness of the service.
Results A total of 354 554 smokers used the Smoking Cessation Clinics in 2009. The self-reported 4-week and 6-month quit rates were 78% and 40%, respectively. Estimated 1-year and 8-year quit rates were 28.1% and 12.9%, respectively. The cost of the service in 2009 was US$21 127 thousand. Cost per service user who set a quit date was US$60. Cost per service user who maintained cessation at 4 weeks, 6 months and 1 year was US$76, US$149 and US$212, respectively. When considering 8-year quit rates, the cost per life-year saved was estimated at US$128 in the base scenario and increased to US$230 in the worst-case scenario.
Conclusion The nationwide government-supported public health centre-based Smoking Cessation Clinics provided highly cost-effective service at a level of 0.46% of the per capita gross domestic product.
- Smoking cessation
- cost–effectiveness analysis
- secondhand smoke
- public policy
- socioeconomic status
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- Smoking cessation
- cost–effectiveness analysis
- secondhand smoke
- public policy
- socioeconomic status
Tobacco smoking is a major public health issue and could be reduced through better understanding of nicotine addiction and application of effective smoking cessation intervention programmes. A wide variety of smoking cessation services have been implemented in many countries, but most of them are Quitline services; nationwide smoking cessation clinics exist in very few countries (ie, the UK, Hong Kong and the Republic of Korea). An evaluation of the cost and effectiveness of these clinics was performed in the UK1 and Hong Kong,2 showing a very high cost–effectiveness and evidence of their important public health role.
Korea has a large population of smokers (47% of men), but a high number of them have the intention to quit (two-thirds of smokers).3 Korea has therefore established nationwide government-supported Smoking Cessation Clinics, which have been operating in 253 public health centres since 2004. These clinics provide behavioural counselling and nicotine replacement therapy (NRT) and represent the first formal smoking cessation service in the public sector, along with toll-free Quitline. However, there has been no evaluation so far on the cost and effectiveness of the public health centre-based Smoking Cessation Clinic services. Therefore, this study aimed to provide this evaluation. Indeed, information on the implementation and evaluation of smoking cessation services in Korea could have important public health and policy implications for countries that are either considering or preparing to implement a clinic-based cessation service.
Public health centre-based Smoking Cessation Clinics in Korea
In Korea, there are 253 public health centres nationwide, located in all administrative districts. Smoking Cessation Clinics were launched at these public health centres in 2004 under the direction of the Ministry of Health and Welfare. After a successful 3-month pilot duration, the Smoking Cessation Clinics rolled out across the country in settings besides public health centres in 2005. The clinics consist of a small number of administrators and doctors and anywhere from one to four trained counsellors, depending on the size of the community.
The public health centre-based Smoking Cessation Clinics provide free behavioural counselling and medication (mostly NRT). At the first visit, smokers who wish to quit are assessed using a structured questionnaire administered by face-to-face interview. Demographic information is collected and smoking habits and related health risk factors are assessed. Nicotine dependency and physical evidence are also assessed using the Fagerström Test for Nicotine Dependence and expired carbon monoxide validation and/or urine cotinine test, respectively. Personal information and interview details are recorded in the electronic database system. Individual counselling is provided based on the information collected in the interview. The smoker sets a quit date and NRT is provided if necessary, free of charge. There are at least three visits, and face-to-face counselling goes on for 6 months. Telephone counselling and texting are also used in addition to face-to-face counselling during the 6-month follow-up. Self-reported continuous abstinence from smoking is reported at 4 weeks, 6 weeks and 6 months. If a service user reported continuous abstinence from smoking for 6 months, he/she is classified as having successfully quit, and clinic service is discontinued. A user who relapses or discontinues the service for any reason can re-enrol.
Source of data
The Smoking Cessation Clinics have an electronic database system to ensure efficient management and to monitor service performance, which is operated by a government-supported institution. All clinic users are registered in the database system. Services provided, including counselling and medication, are also recorded and subsequent visits are scheduled in the database system. The data used to evaluate the effectiveness of the Smoking Cessation Clinics were collected from this database system—the number of service users, the number who maintained cessation at 4 weeks and 6 months and the proportion who received NRT or behavioural counselling only. The most recent data (ie, from 2009) were used for this cost–effectiveness analysis. The annual report and the financial report of the public health centre-based Smoking Cessation Clinics were also used as a source of data.
Cost of the service
The cost estimates contain the following components: staff salary costs, medication costs (mainly NRT but also some bupropion), costs of education and promotion for the public, overhead and operating costs. These costs were calculated from the 2009 financial report, which combines central and local government expenditure for the public health centre-based Smoking Cessation Clinics. The average monthly salary of a clinic counsellor was also collected from an anonymous self-administered questionnaire during compulsory education programmes for these counsellors. No administrator cost or doctor's salary was included in the cost of the service, as all public health centres have appointed government officials and doctors who fulfil the necessary administrative and prescription duties.
The actual price of NRT per pack (1 pack=1-week supply), which are bought in bulk by clinics, was also investigated. Despite variations among public health centres and NRT brands, the average purchase price was negotiated at 80% of the market price.
About 17% of total expenditure was allocated for Smoking Cessation Clinic promotion and antismoking campaigns, as well as for smoking prevention and cessation education. New purchase and maintenance costs of computers, carbon monoxide monitors and other equipment and supplies were included in overhead and operating costs. There is no rent for counsellors' rooms, as all public health centres provide the room for this service. All costs in this report are presented in US$ according to the average 2009 exchange rate (US$1=1200 KRW).
Health benefits and savings
The number of service users who set a quit date, self-reported 4-week and 6-month quit rates and the proportion of NRT users were routinely collected from the Smoking Cessation Clinic performance monitoring database system. The mean duration of NRT use was calculated based on the actual medication cost per NRT user (ie, US$17.7= cost for 2-week supply). Estimated 1-year quit rate was based on the 1-year relapse rate reported in 2009 by a nationwide telephone survey targeting 4001 randomly selected Smoking Cessation Clinic users. The survey data showed that 22% of service users who had maintained cessation for 6 months would relapse. To avoid overestimating the service's effectiveness, we adjusted these data for the background (ie, unaided) population cessation rate. This background rate reflected the potential quit rate that motivated smokers could achieve with minimal support. Before the establishment of Smoking Cessation Clinics and Quitline in 2004, there were very few opportunities for smokers to obtain intensive cessation interventions from the Korean government. Therefore, we assessed 1-year cessation rates in the 2004 National Smoking Prevalence Survey.4 To do this, we estimated the number of men who were smokers 1 year prior to the 2004 survey and had quit at the time of the survey, as per a formula that has already been described in the literature using Korean data.5 The resulting estimated 1-year cessation rate in 2004 was 3.1% and was applied as the background population cessation rate. We did not assess 1-year cessation rates for women because their surveyed prevalence rate was significantly underestimated6 and the proportion of female Smoking Cessation Clinic users was relatively small (10%).
It has been reported that half of smokers who maintain cessation for 1 year will relapse within the subsequent 7 years,7 and these smokers will not benefit from the health gains accrued by quitting.1 Recent data on these health gains have been published.8 After discounting at the recommended 3.5% as recommended by the English National Institute for Health and Clinical Excellence,9 this provided an average estimate of 3.6 life-years gained per quitter.
All estimates included in the analysis may have some variation. Cost estimates of the service were more stable than effectiveness estimates, as cost estimates were extracted from the fiscal report. Conversely, effectiveness estimates depended on the short- and long-term quit rate, the most sensitive variable. In the base analysis, self-reported 4-week and 6-month quit rates were used to estimate effectiveness. Based on previous literature that reported on the agreement between self-reported smoking cessation and urinary cotinine test or carbon monoxide validation among Smoking Cessation Clinic users,10 ,11 the negative predictive value of self-report in detecting smoking status was 60%–96%. A worst-case scenario was also elaborated, in which a 40% decreased quit rate at 4 weeks and 6 months was used, consequently decreasing the 8-year quit rate and life-years saved.
Table 1 shows smoking-related characteristics of the 354 554 smokers who enrolled in the public health centre-based Smoking Cessation Clinics in 2009 compared with smokers in the general population as reported by the Korea National Health and Nutrition Examination Survey.3 The proportion of female clinic users was 10.3%, and mean age of users was 44.1 years. The clinic users smoked a higher average number of cigarettes per day (20 cigarettes/day), had a longer mean duration of smoking (24.4 years) and had more past quit attempts (76.5%) than smokers in the general population.
Table 2 shows the service performance and expected effect of the Smoking Cessation Clinics in 2009. A total of 544 counsellors (number of full time equivalent) worked at the clinics at the time. NRT was used by 70.0% of service users for an average of 2 weeks. The self-reported 4-week and 6-month quit rate was 78% (276 552 smokers) and 40% (141 821 smokers), respectively. The estimated 1-year quit rate was 28.1% (99 630 smokers), based on the aforementioned 1-year relapse rate reported in the nationwide telephone survey and the 3.1% background quit rate estimated from the 2004 National Smoking Prevalence Survey. The 8-year quit rate was estimated at 12.9% (45 830 smokers), by applying the 54% relapse rate among those who maintained cessation for 1 year.7 This yielded a total of 164 987 life-years saved by quitting smoking (3.6 life-years per quitter) (table 2).
Table 3 shows the costs of Smoking Cessation Clinic services in 2009. According to the 2009 financial report, a total of US$21.1 million was spent to finance these services. Total cost of counsellors was US$8.9 million (43% of total expenditure). The mean annual salary per counsellor was US$15 833 and corresponded exactly to the information collected from the self-administered counsellor survey. Medication cost was consistent with the cost of NRT (US$4.3 million) and other medication (US$1.1 million). The mean cost was US$17.5 per NRT user and was approximately the same as the cost of a 2-week supply of NRT. There was a US$3.5 million expenditure for promotion and education costs for the community, including schools and workplaces. The remaining US$3.0 million was spent on overhead and operating costs (table 3).
Table 4 shows estimates of the cost–effectiveness of Smoking Cessation Clinic services in 2009. Cost per service user who set a quit date was US$59.6. Cost per user who maintained cessation for 4 weeks, 6 months and 1 year was US$76.4, US$149.0 and US$212.1, respectively. The cost per life-year saved among those estimated to maintain cessation for 8 years was expected to be US$128.1 and increased to US$230.4 in the worst-case scenario (table 4).
Korea has made significant progress in reducing the cigarette smoking rate among adult men, which has fallen from 66% in 1998 to 47% in 2009.3 Although the rate of smoking among men is still high, a large proportion of smokers do have a willingness to quit. About 58% of current smokers have tried to quit in the last year, and two-thirds of them plan to quit smoking someday.3 Furthermore, Korea ratified the WHO's Framework Convention on Tobacco Control in 2005. In 2008, the WHO launched the MPOWER package against the global tobacco epidemic and the Korean government achieved the highest score on the ‘O’ standing for ‘offer help to quit’ with the free national public health centre-based Smoking Cessation Clinics and Quitline services.12 Evaluation of governmental efforts to support smoking cessation have been performed, but were limited, with measurements focusing mostly on the quantitative effect of services (eg, the number of users and quit rate).
Therefore, the present results on the cost and effectiveness of the Korean nationwide public health centre-based Smoking Cessation Clinics might be considerably useful to map out future directions of the service. Based on the self-reported quit rates at 4 weeks (78%) and 6 months (40%), the estimated relapse rate and background quit rate, the number of smokers who maintained cessation at 1 year was estimated at 99 630 (28.1% of service users). The estimated cost per life-year saved was US$128.1 (US$230.4 in the worst-case scenario) and total life-years saved from quitting smoking was 164 987 (3.6 life-years per quitter). The actual health gains accrued by quitting smoking were halved when the 8-year relapse rate was considered.8 Korean nationwide public health centre-based Smoking Cessation Clinics are highly cost-effective at the level of 0.46% of the per capita gross domestic product (GDP), which is a generally used reference for decision making in Korea.
Long-term quitters reduce their risk of developing smoking-related diseases and consequently reduce healthcare costs. In 2003, 1.3 million patients were suffering from smoking-related diseases. In the same year, the Korean National Health Insurance (KNHI), which is mandatory for all Koreans, showed a total medical expenditure attributable to smoking of US$413.7 million (US$307.1 per patient).13 According to the literature,13 the proportion of KNHI patients suffering from smoking-related diseases was 6.1% of the total number of KNHI patients over 30 years of age. When we consider that around 85% of the Korean population uses the KNHI at least once a year,14 this would mean that approximately 5% (ie, 0.85×0.061) of the general population aged 30 years or older could develop smoking-related diseases. If we assume that long-term quitters reduce their risk to that of a non-smoker, 5% of people who have maintained cessation for 8 years (N=2292) in our study could avoid smoking-related diseases, and the KNHI could save US$879 thousand in related medical costs (2292 averted patients × US$307 × 1.25 weight for medical costs not covered by KNHI13) in 1 year (data not shown).
The cost per quitter (between US$76.4 and US$212.1 for the 4-week to 1-year range) and life-years saved was comparable to or lower than that of the National Health Service (NHS) Stop Smoking Services in the UK and the Hong Kong Smoking Cessation Health Center when the GDP and price level in the two countries were considered. The NHS Stop Smoking Services in the UK were established in 1999 to provide support for motivated smokers who wish to quit. Their service users are offered pharmacotherapy and behavioural therapy in groups or individual settings. Around 13% of clients achieved smoking cessation for at least 1 year in 2000/2001, and services are very cost-effective, with an average cost per life-year saved, after allowance for future healthcare savings, of 438 Pound Sterling (UKP) in 2000/2001,1 which was over 50 times lower than the National Institute for Health and Clinical Excellence's benchmark cost–effectiveness figure of 30 000 UKP.9 In Hong Kong, the Smoking Cessation Health Centre, a hospital-based smoking cessation clinic, provides individual behavioural counselling and NRT. The quit rate at 12 months was 27% and the average cost per quitter who quits for at least 1 week was US$339 (US$440 including NRT cost for a free 1-week supply) from 2000 to 2002.2
Other cessation programmes in Eastern and Western countries do not have exactly the same structure as the Smoking Cessation Clinics, but they are also cost-effective. In Thailand, for example, more than 1000 trained community pharmacists provide smoking cessation services. This structured community pharmacist-based smoking cessation (CPSC) programme has been shown to be cost-effective when compared with usual care. The CPSC programme results in a cost savings of US$500 for the health system and life-year gains of 0.18 years for men and costs savings of US$614 and life-year gains of 0.24 years for women.15 The CPSC programme provides personalised and supportive advice on smoking cessation, appropriate therapy with self-help materials and seven scheduled 10 min follow-up visits.
Another example is the 3-year trial of low-intensity intra-worksite intervention on smoking cessation that was carried out in Japanese employees. This intervention consisted of presenting information on the harms of smoking and the benefits of cessation through posters, a website and newsletters; smoking cessation campaigns; creation of designated smoking areas and periodic site visits to the designated smoking areas by an expert. The quit rate of 6 months or longer was 12.1%, and the cost per additional quitter due to the intervention was 70 080 Japanese Yen (equivalent to US$610 in 2005).16 New York City undertook large-scale distribution of free NRT and followed up with recipients after 6 months. The 6-month quit rate among NRT recipients was 20%, with a cost of US$464 per quit.17
In the present study, it is possible that there are underlying moral hazards and waste regarding NRT distribution and use if smokers receive free NRT systematically, instead of only when it is deemed necessary. These results can be considered very cost-effective nevertheless, even in the worst-case scenario.
Although there are important political and practical implications of the present study results, there are things to take into consideration, including some limitations. The self-reported quit rate at 4 weeks (78%) and 6 months (40%) and estimated quit rate at 1 year (28%) among Korean Smoking Cessation Clinic users was much higher than that in the UK's NHS Stop Smoking Service users (43%–53% at 4 weeks and 13%–15% at 1 year, carbon monoxide validated1 ,18), as well as results from the USA (22% at 1 year19), New Zealand (14% at 6 months, self-reported20), Hong Kong (27% at 1 year, self-reported2) and Guangzhou, China (24% at 6 months, self-reported21). There are several possible reasons for the high success rate of the Korean Smoking Cessation Clinics. First, if clinic users fail, they are able to re-enrol in the programme at any time. Repeated attempts to quit smoking may lead to higher success rates. The proportion of re-enrolment was 18% between 2005 and 2009.
Second, as shown in a systematic review of 67 published reports, self-reported quit rate may be higher than a biochemically validated quit rate and sensitivity levels for self-reported estimates vary depending on the population studied and the biochemical test used as a gold standard.22 The validity of self-reported quit rates has been tested in Korea. One study reported an excellent agreement score between self-reported smoking status and urinary cotinine (κ coefficient, 0.79; 95% CI 0.70 to 0.88) based on data from 294 participants of four Smoking Cessation Clinics and their 4-week quit rate.11 Another study included 52 participants from seven Smoking Cessation Clinics; their 12-week quit rate yielded a relatively low agreement score (κ coefficient, 0.37; 95% CI 0.26 to 0.48).10 The negative predictive value of self-reporting in these studies also varied between 60% and 96%.10 ,11 In the present study, we chose to apply the 60% level of self-reported quit rate for the sensitivity analysis.
Third, most Smoking Cessation Clinic users were fully motivated to quit smoking and voluntarily visited the clinic. An intension to quit may lead to a higher success rate. As shown in table 1, clinic users had more past quit attempts (76.5%) than smokers in general population (57.2%).
Lastly, high NRT use could have led to a high success rate. Most Korean Smoking Cessation Clinic users (70%) received NRT free of charge. The effectiveness of NRT to stop smoking is well established,23–25 and NRT has also been routinely used (65% in 200926) in the NHS Stop Smoking Services in the UK.
We adopted foreign data7 for long-term cessation of more than 1 year, as no representative data are available in Korea due to the short history of the service and lack of follow-up system for service users. This must also be considered in order to obtain a more precise estimation of the cost–effectiveness of Korean Smoking Cessation Clinics.
Acceptable cost–effectiveness thresholds for public health services are still controversial, and Korea has no official threshold. The WHO suggested that interventions with a cost–effectiveness ratio under the GDP per capita would be ‘highly cost-effective’ and below three times the GDP per capita ‘cost-effective’.27 The GDP per capita for Korea reported by OECD statistics (http://www.oecd.org) was US$27 658 in 2008.
Consequently, although the limitations of the study include an especially high quit rate without biochemical validation and no data on Korean-specific long-term quit rates or life-years saved from quitting smoking, the present study has provided the first detailed descriptive data on the cost and effectiveness of the Korean public health centre-based Smoking Cessation Clinics. Further studies on the validation of quit rate, long-term relapse rate and effectiveness of smoking cessation services are needed. This study can also provide policy implications for countries, in particular those with high smoking prevalence, where a clinic-based cessation programme is being considered or prepared.
What this paper adds
Nationwide smoking cessation clinics exist in very few countries and the data on their cost and effectiveness are lacking.
The present study adds to the current evidence on the cost–effectiveness of smoking cessation clinics, using data from nationwide government-supported Smoking Cessation Clinics in Korea, a country with a large population of smokers.
This study could also have important policy implications for other countries, in particular those where there is a high prevalence of smoking or where a clinic-based cessation programme is being considered or prepared.
Funding This study was partially supported by the National Cancer Center (grant nos. NCC-1010250) and the Ministry of Health and Welfare.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement The data on the performance of the Korean Public Health Center-based Smoking Cessation Clinics are published annually as an internal report, and these are available from the Korean government, Ministry of Health and Welfare, at the request.
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