• Paul G Barnett, Rosalinda V Ignacio, Hyungjin Myra Kim, Mark C Geraci, Carol A Essenmacher, Stephanie V Hall, Scott E Sherman, and Sonia A Duffy.
• Health Economics Resource Center, VA Palo Alto Healthcare System, Menlo Park, CA, USA.
• Addiction. 2019 Aug 1; 114 (8): 1436-1445.

Background And AimsCost-effectiveness studies in randomized clinical trials have shown that tobacco cessation pharmacotherapy is among the most cost-effective of health-care interventions. Clinical trial eligibility criteria and treatment protocols may not be followed in actual practice. This study aimed to determine whether tobacco cessation pharmacotherapy is cost-effective in real-world settings.DesignA retrospective analysis of costs and outcomes.SettingHospitals and clinics of the US Veterans Health Administration, USA.ParticipantsA total of 589 862 US veterans who screened positive for tobacco use in 2011.Intervention And ComparatorTobacco users who initiated smoking cessation pharmacotherapy in the 6 months after screening were compared with those who did not use pharmacotherapy in this period. Pharmacotherapy included nicotine replacement therapy, bupropion (if prescribed at 300 mg per day or specifically for tobacco cessation) or varenicline.MeasuresEffectiveness was determined from responses to a subsequent tobacco screening conducted between 7 and 18 months after the treatment observation period. Cost of medications and prescribing health-care encounters was determined for the period between initial and follow-up tobacco use screening. Multivariate fixed-effects regression was used to assess the effect of initial treatment status on cost and outcome while controlling for differences in case-mix with propensity weighting to adjust for confounding by indication.FindingsThirteen per cent of participants received tobacco cessation pharmacotherapy within 6 months of initial screening. After an average of an additional 218.1 days' follow-up, those who initially received pharmacotherapy incurred $143.79 in additional treatment cost and had a 3.1% absolute increase in tobacco quit rates compared with those who were not initially treated. This represents an incremental cost-effectiveness ratio of $4705 per quit. The upper limit of the 99.9% confidence region was $5600 per quit. Without propensity adjustment, the cost-effectiveness ratio was $7144 per quit, with the upper limit of the 99.9% confidence region $9500/quit.ConclusionsTobacco cessation pharmacotherapy provided by the US Veterans Health Administration in 2011/12 was cost-effective in this real-world setting, with an incremental cost-effectiveness ratio of $4705 per quit.© 2019 Society for the Study of Addiction.

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