Elsevier

The Lancet

Volume 354, Issue 9174, 17 July 1999, Pages 210-215
The Lancet

Articles
Prescription of transdermal nicotine patches for smoking cessation in general practice: evaluation of cost-effectiveness

https://doi.org/10.1016/S0140-6736(99)90001-6Get rights and content

Summary

Background

The 1998 UK government White Paper Smoking Kills emphasises that normal practice should be for general practitioners (GPs), practice nurses, and others to offer advice and support to smokers in their efforts to stop. However, GPs are not allowed to write NHS prescriptions for nicotine-replacement therapy, even though this is the only effective pharmceutical treatment available in the UK. We estimated the cost-effectiveness, for the NHS, of allowing GPs to prescribe transdermal nicotine patches for up to 12 weeks.

Methods

We used data from a randomised, placebo-controlled efficacy trial of nicotine patches and a survey of associated resource use in 30 GP surgeries in 15 English counties. We calculated the health benefit of nicotine-patch treatment in number of life years that would be saved by stopping smoking at various ages, and used an abstinence-contingent treatment model to calculate the incremental cost per life year saved by GP counselling with nicotine-patch treatment over GP counselling alone. Cost effectiveness was assessed on the basis that GPs would provide repeat NHS prescriptions for up to 12 weeks if the treatment was proving successful.

Findings

If GPs were allowed to prescribe transdermal nicotine patches on the NHS, for up to 12 weeks, the incremental cost per life year saved would be: £398 per person younger than 35 years; £345 for those aged 35–44 years; £432 for those aged 45–54 years; and £785 for those aged 55–65 years.

Interpretation

The low cost per life year saved would make GP intervention against smoking a cost-effective life-saving treatment. The priniciples of the government White Paper could be cost-effectively extended into general practice to reduce smoking and smoking-related illnesses.

Introduction

The enormous toll of cigarette smoking on public health has been known for many years. Smoking-related diseases account for almost 20% of mortality in more developed countries.1 Individuals who smoke throughout their lives have a 50% risk of dying prematurely and have a life expectancy that is 8 years less than those who have never smoked.2 Because the number of people smoking has stopped declining in the past few years and uptake of smoking among young people has remained fairly constant,3 there is an urgent need for effective interventions to encourage cessation

The financial burden on health-service resources in the treatment of smoking-related diseases is about £1·7 billion every year in the UK.4 Despite overwhelming evidence that nicotine-replacement therapy (NRT) is effective in helping smokers to stop,5 general practitioners (GPs) cannot give a National-Health-Service (NHS) prescription for NRT, only a private one. In the White Paper on smoking, Smoking Kills, the UK government proposed a limited correction to this anomaly.6 The report acknowledges that smoking is highly addictive, and that about 70% of smokers want to give up but seem unable to do so despite repeated attempts. The White Paper offers “real support from the NHS to help smokers quit”. Support comes through promotion of new specialist smoking-cessation services, which are allowed to provide free NRT to those exempt NHS prescription charges for only 1 week, within a fixed budget of just over £60 million for 3 years. By any standards this intervention is a modest start at tackling such a major and, until now, largely neglected health issue. We aimed to estimate the cost-effectiveness of extending this treatment into general practice and allowing GPs to continue prescribing NRT for up to 12 weeks, if the treatment is proving successful.

In our placebo-controlled trial of 1200 heavy smokers in 30 general practices we previously showed that the 16 h transdermal nicotine patch doubled the 1-year sustained-success rate achieved by brief GP counselling alone.7, 8 Another large trial showed a 24 h nicotine patch to be similarly effective in this setting.9 As part of our trial, a survey of participating GPs was done to assess the health-care resources used in treatment. From these data, and data from other reported sources, we have estimated the incremental cost-effectiveness of patch treatment—ie, the extra cost required to save each extra life year, over the option of brief GP counselling alone, assuming the costs are met by the NHS.

Section snippets

The treatment and resource use trial

Heavy smokers have a high risk of developing a smoking-related illness10 and are more highly dependent on nicotine and hence less successful at stopping without help than people who smoke less.8 The specific aim of our previous trial was to target more dependent smokers (smoking more than 14 cigarettes per day) who were motivated to stop, and selection for inclusion was based on responses to a short screening questionnaire and the judgment of the GPs. Our criteria for selection based on the

Results

The incremental cost-effectiveness ratios for the NHS treating a new patient at various ages with the nicotine patches are shown in table 3. The difference in cost-effectiveness for those treated at different ages reflects the competing effects of LYS, discounting, lifetime unaided quitting, and differing NHS prescription exemption rates. The balance of these factors suggest that the intervention would be marginally more cost-effective in individuals aged 35–44 years. The treatment is less

Discussion

Previous studies have assessed the cost-effectiveness of nicotine-patch treatment but this study is different in that it was done in a general-practice setting and was based on a large efficacy trial that also incorporated a direct assessment of the health-care resources used. The results show that GP intervention with the nicotine patch would be very cost-effective if funded by the NHS. Even allowing for the differing method used to assess the cost-effectiveness of other treatments, the

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