Full text of DOI:10.1006/pmed.2000.0756

Preventive Medicine 31, 641–648 (2000)
doi:10.1006/pmed.2000.0756, available online at http://www.idealibrary.com on
Cost-Effectiveness Analysis of a Family Physician Delivered
Smoking Cessation Program1
David J . Buck, B.Sc. M.Sc.,* Robyn L. Richmond, M.A., Ph.D.,†,2 and Colin P. Mendelsohn, M.B., B.S.†
*Department of Dental Public Health & Oral Health Services Research, Guy’s, King’s and St. Thomas’ (GKT) Dental Institute,
King’s College, London, United Kingdom; and †School of Community Medicine, University of New South Wales, Australia
for r etr osp ective cost-effectiven ess a n a lysis of in ter -
Objectives. Th e objectives w er e to p r esen t a cost-
effectiven ess a n a lysis of a sm ok in g cessa tion p r ogr a m
d eliver ed by p h ysicia n s a n d com p a r e r esu lts to oth er
sm ok in g cessa tion in ter ven tion s.
ven tion s.
᭧ 2000 Am er ica n Hea lth F ou n d a tion a n d Aca d em ic P r ess
Key Wor d s: cost-effectiven ess; fa m ily p h ysicia n s;
sm ok in g cessa tion in ter ven tion .
Meth od s. Retr osp ective effectiven ess figu r es fr om a
p r eviou s eva lu a tion of th e sm ok in g cessa tion p r ogr a m
w er e su p p lem en ted w ith estim a tes ba sed on r e-
sea r ch ed a ssu m p tion s. Net a bstin en ce r a tes w er e d e-
ter m in ed for sm ok er s, d ep en d in g on th eir sta ge of
r ea d in ess to qu it, th a t is, “p r ep a r ed ,” “con tem p la tive,”
a n d “p r econ tem p la tive,” lea d in g to a n a ssessm en t of
th e n u m ber of sm ok er s a ch ievin g a bstin en ce a s a r esu lt
of th e Sm ok escr een in ter ven tion . Costs w er e ca lcu -
la ted fr om th e p er sp ectives of sm ok er s, fa m ily p h ysi-
cia n s, or ga n izer s, tr a in er s, a n d a ll p a r ties com bin ed .
Assu m p tion s w er e va r ied w ith a sen sitivity a n a lysis.
Resu lts. Ba selin e costs p er a d d ition a l a bsta in er w er e
$183 ba sed on p h ysicia n s’ in ter ven tion costs a t 1995
p r ices. Th is is th e figu r e m ost com p a r a ble to p r eviou sly
con d u cted econ om ic eva lu a tion s of sm ok in g cessa tion
in ter ven tion s. Sen sitivity a n a lysis va r yin g th e p er -
sp ective a n d u n d er op tim istic a n d p essim istic a ssu m p -
tion s a bou t effectiven ess p r od u ced a w id e va r iety of
estim a tes. Th e d ecision to in clu d e or exclu d e tr a in in g
costs h a d a p a r ticu la r ly im p or ta n t bea r in g on th e esti-
m a tes. How ever, u n d er r ea son a ble a ssu m p tion s th e
cost p er a d d ition a l qu itter com p a r es fa vor a bly to
sm ok in g a n d oth er m ed ica l a n d h ea lth ca r e in ter ven -
tion s w or ld w id e.
INTRODUCTION
There is clear evidence from randomized trials that
family physicians who intervene with their smoking
patients significantly influence their behavior, for ex-
ample, in the United States [1–3], the United Kingdom
[4,5], Canada [6,7], and Australia [8,9]. There is also
increasing evidence that this intervention by physi-
cians is cost-effective relative to other common clinical
interventions [10,11]. Although physicians still have a
relatively low rate of identifying and intervening with
smokers in routine clinical practice [12,13], they pro-
vide more smoking cessation interventions if they re-
ceive more training [6,14–17].
The objective of this article is to present a cost-effec-
tiveness analysis of a physician delivered smoking ces-
sation intervention called Smokescreen for the 1990s,
which included substantial training. The novelty of this
study is that it is different from other economic evalua-
tions of smoking cessation programs on five counts.
First, it is one of the few economic evaluations to our
knowledge that includes the costs of the preinterven-
tion training workshops for physicians. Second, it pres-
ents results from how this affects headline cost-effec-
tiveness figures. Third, it reports cost-effectiveness
figures from the perspective of smokers, family physi-
cians, sponsoring health bodies, and all these parties.
Con clu sion s. Th e p r ogr a m a p p ea r s cost-effective
w h en com p a r ed to oth er sm ok in g cessa tion a n d h ea lth
p r om otion in ter ven tion s a n d illu str a tes th e p oten tia l
1
This project was funded by the National Drug and Alcohol Re-
search Centre, University of New South Wales, and the Drug and Fourth, it is one of the few studies that uses smoking
Alcohol Directorate of the New South Wales Department of Health.
To whom reprint requests should be addressed at School of Com-
munity Medicine, University of New South Wales, Kensington, NSW
2052, Australia. Fax: 612 9313 6185. E-mail: R.Richmond@
unsw.edu.au.
patients who were not volunteers, or otherwise self-
selected subjects. Finally, it intervenes differently with
smokers according to their readiness to change
smoking.
2
641
0091-7435/00 $35.00
Copyright ᭧ 2000 by American Health Foundation and Academic Press
All rights of reproduction in any form reserved.

642
BUCK, RICHMOND, AND MENDELSOHN
METHODS
smokers—a total of 6,529. Figure 1 also shows the fol-
low-up procedure with prepared smokers. Of the initial
1,804 prepared or “ready” smokers 840 dropped out
because of missing bookmarks—the most common rea-
sons for this were patients did not want an intervention,
physicians forgot to fill in details, and bookmarks were
lost, were illegible, or incorrectly completed. Of those
with bookmarks (964) a further 236 were lost to follow-
up—the most common reasons were could not be lo-
cated, requested no follow-up, deceased, refused, or had
no telephone. For those successfully followed-up (40%),
the time elapsed since recruitment to the program var-
ied with a mean of 9.9 months (SD ϭ 2) and a range
The economic evaluation is based on a previously
completed research project that evaluated the utiliza-
tion of Smokescreen by family physicians in Sydney
and New South Wales in 1991–1992 and the abstinence
rates among their patients. A detailed discussion of the
methods of that research project is described else-
where [17].
The Intervention: Smokescreen for the 1990s
Smokescreen for the 1990s is a smoking cessation
program based on the “Transtheoretical Model” or the
“Stage of Readiness to Change Model” [19,20]. Physi-
cians were trained to assess the stage of their smoking of 5–13 months. This occurred because patients were
patients regarding their desire to quit into precontem-
plation, contemplation, or preparation stages. Precon-
templative smokers were given a “not ready” booklet
and invited to return when ready to discuss cessation.
Contemplative patients received an “unsure” booklet
and a brief motivational interview. Prepared smokers
received a “ready” booklet and a program of three visits
of cognitive and behavioral strategies and advice on
how to use nicotine chewing tablets. Follow-up details
of participating prepared smokers were recorded with
a bookmark.
recruited opportunistically throughout the 6-month re-
cruitment period and the study endpoint was fixed fol-
lowing physician training.
Patient’s self-reported point prevalence abstinence
was verified by expired carbon monoxide readings of
Ͻ14 ppm. Validation for the vast majority of smokers
was carried out within 24 h. A small number in rural
areas were validated within 7 days of claiming to have
quit. Even so, these subjects, in common with all others,
were unaware they would be asked for biochemical vali-
dation and therefore had no incentive to change their
behavior in the period up to a week between their cessa-
tion claim and validation. The study abstinence rate
was 22% (159/728), adjusted to 21% after applying the
validation failure rate of 5%. Deceased patients were
Patient Outcomes
Recruited prepared smokers were contacted by tele-
phone at 12 months post-physician training to deter-
mine smoking status. Figure 1 shows the initial num-
bers of prepared, contemplative, and precontemplative treated as being continuing smokers.
2092 precontemplative
smokers
F IG. 1. Step diagram of smokers.

COST-EFFECTIVENESS ANALYSIS
643
part of the study and were targeted according to self-
assessed stage of change before recruitment. In addi-
tion, no validation of stated quit rates was undertaken.
Djikstra et al.’s [22] control group is therefore very dif-
ferent from ours and smokers in general. In particular
they were volunteers—and hence it is not surprising
that they have higher natural abstinence rates.
TABLE 1
Baseline Assumptions about Effectiveness of Smokescreen with
“Ready” Smokers
Step
Decision
2
For patients without bookmarks (n ϭ 840):
All assigned an abstinence rate half that of the step 5 verified
abstinence rate of 21% (adjusted for natural abstinence rate).
Contemplative and precontemplative smokers. In
the patient intervention phase of the study a total of
6,529 interventions were completed. Of these 4,725
(72%) were delivered to nonprepared smokers, 2,633
(40%) to contemplators, and 2,092 (32%) to precontem-
plators. This accords well with the proportions of such
smokers found in another Australian study [23]. In the
absence of abstinence rates for nonprepared smokers,
we must rely on estimates of abstinence rates from
other sources, a tactic that previous economic evalua-
tions of smoking cessation have adopted for the entire
evaluation [24–26].
3
For patients with bookmarks subsequently missing follow-up
(n ϭ 236):
(i) Those unwilling to be followed-up after intervention —Natural
abstinence rate of “ready” smokers (n ϭ 35).
(ii) Those not followed up due to refusal—Continuing smokers
(n ϭ 7).
(iii) Remainder —Step 5 verified abstinence rate (adjusted for nat-
ural abstinence rate) (n ϭ 194).
4
For patients too distant for biochemical validation (n ϭ 50):
Step 5 verified abstinence rate (adjusted for natural abstinence
rate).
Effectiveness Issues
Prepared smokers. The figures above apply to 40%
(728/1,804) of all prepared smokers seen. Decisions are
required about how effective Smokescreen was for the
remaining prepared smokers who missed follow-up or
biochemical validation. We make conservative assump-
tions. In Table 1 we assume that quit rates for smokers
without bookmarks at step 2 in Fig. 1 are half that of
smokers with bookmarks (this assumption is varied in
the sensitivity analysis later).
In step 3 of Fig. 1, 236 smokers missed follow-up for
a variety of reasons. Richmond et al. [17] made the
decision to count only those who refused to be contacted
after initially agreeing to follow-up as continuing smok-
ers (n ϭ 7), while the others were assumed to have a rate
similar to those followed-up. We are more conservative,
allocating those who missed follow-up for various rea-
sons on the basis of Table 1.
Effectiveness Estimates: Prepared Smokers
(a) Those followed-up. For those 728 patients fol-
lowed-up (Fig. 1), the abstinence rate was 21%, which,
when adjusted for a natural abstinence rate of 8%, re-
sults in a net abstinence rate of 13% (a net number of
95 abstinent).
(b) Those not followed-up. Of those 236 who
“missed” follow-up, 194 (82%) are due to reasons that
are unlikely to affect abstinent rates and these are as-
sumed to have the net abstinence rate of 13%, as above
(an additional 25 abstinent). The remainder of the 236
either requested no follow-up (n ϭ 35) or refused contact
at follow-up (n ϭ 7). Smokescreen is assumed to have
led to no additional net abstainers from this group.
(c) Smokers without bookmarks. Eight hundred
forty of the original 1,804 prepared smokers were with-
out bookmarks for various reasons. In order to reflect
this general lack of effort by physicians and enthusiasm
of smokers, a net abstinence rate for the intervention
which is half that (6.5%) for those with returned book-
marks is assumed (an additional 55 abstinent).
“Natural” abstinence rates. In order to avoid overes-
timating the net effectiveness of Smokescreen, it is im-
portant to know how many smokers would have been
abstinent at follow-up without intervention. Viswes-
veran and Schmidt [21] conducted a metaanalysis of
41 smoking cessation studies with control groups and
found an average control group quit rate of 6%. We
regard this an estimate of the “natural” quit rate among
all smokers. This accords with Velicer ’s judgment of
how quit rates at 10 months translate to our situation
(personal communication). Similar rates at 10 weeks
Effectiveness Estimates: Nonprepared Smokers
For the 2,633 contemplative smokers who received a
rather than 10 months were found in a Dutch study brief intervention, we assume a small additional net
where a control group was split into precontemplators, effect due to Smokescreen —one-quarter that of
contemplators, and prepared smokers [22]. However, Smokescreen’s net effect with prepared smokers
these smokers were recruited through different means (3.25%, an additional 86 abstinent). For precontemplat-
than in the current study: in particular, a prize was ing smokers who received a booklet only, we assume
offered to those willing to take part and smokers were that Smokescreen has no additional effect over the nat-
asked to first telephone and then write in to become ural abstinence rate (2%) in the short-run.

644
BUCK, RICHMOND, AND MENDELSOHN
Effectiveness Estimates: All Smokers
However, the issue of attrition is more complex than
this. It seems reasonable to assume that some physi-
cians lost to attrition may have changed their practice
as a result of attending the workshop. We return to this
in the sensitivity analysis later.
Summing the figures above gives an estimate of 261
smokers who are abstinent as a result of the Smoke-
screen intervention who would otherwise not be. This
figure is used in the derivation of our cost-effectiveness
ratios below.
Intervention Costs: Physicians
The Cost of Smokescreen
The costs of the intervention to the physician consist
of the opportunity costs of the time taken to intervene
with patients and the cost of the kit. For smoking pa-
tients there are travel costs and opportunity costs of at-
tendance.
We have provided as comprehensive and realistic a
costing as possible, in notable contrast to many other
cost-effectiveness studies of smoking cessation [27].
Costs are included for the workshop organizers, physi-
cian attendees, and final physician users of Smoke-
screen and patients. Assumptions were made and value
judgments reached on some issues. This is a conse-
quence of the imprecise nature of costing. All costs are
in 1995 U.S. dollars to facilitate comparison with other
published studies. Costs were reflated by GDP deflators
to 1995 domestic prices using data from IMF [28] and
then converted to U.S. dollars via GDP Purchasing
Power Parities (PPPs) from OECD [29].
● Each of the 198 physicians in the study purchased
a kit at $67 per kit, a total of $13,180.
For the nonprepared smokers the cost of the interven-
tion, a brief talk and delivery of a pamphlet, is assumed
to take an extra 2 min on top of the time of a usual
consultation for the precontemplative smokers and 4
min for the contemplative smokers (including a motiva-
tional interview). All timings are based on a pilot study
undertaken in one of the author ’s medical practice
(C.M.), and participants in the workshop were advised
these were reasonable for the respective interventions.
Given the numbers of smokers in these groups, this
implies the equivalent of an extra 279 consultations of
15 min for precontemplative smokers and 702 consulta-
tions for contemplative smokers.
● At an average consultation fee in 1991 for a 15-
min consultation of $16, this implies total opportunity
costs of $16,040 for intervening with nonprepared
smoking patients.
We assume it took 5 min to deliver the intervention
to prepared smokers in the initial opportunistic consul-
tation (an addition of 601 consultations) but there are
also the additional costs of the extra visits. While the
program specified an extra two visits per smoker, this
did not occur in all cases [17]. In fact, an average of
0.296 visits were made per smoker, a total of 534 for
the 1,804 prepared smokers in this study.
Workshop Costs
The physician training workshops for Smokescreen
included a 2-h interactive session incorporating the use
of videos and slides, fully described elsewhere [17,30],
and an hour for dinner. There were 29 workshops at-
tended by 429 physicians and 71 other health care pro-
fessionals. The workshops were costed from the per-
spectives of the organizers and the attendees. Costs
to the organizers included administration, invitations,
postage and secretarial support, travel costs, trainer
salary, trainer accommodation when appropriate, costs
of room and equipment hire, and dinner and drinks.
Costs to the physicians were travel and opportunity
costs of time. We did not include the costs of the other
health professionals attending, since the intervention
was designed for family physicians. Detailed costings
can be provided by the authors on request.
● For the 1,804 “prepared” smokers in the study, this
implies a total opportunity cost to the physician of
$18,559.
There were 198 of the 429 attending physicians who
purchased the Smokescreen kit and were willing and
eligible to participate in the study and be followed-
up to assess their effectiveness. We assume that the
attrition seen here (n ϭ 231) reflects “natural wastage”
that would be duplicated in any further training situa-
Intervention Costs: Smokers
Few significant extra costs are incurred for an indi-
tion. Therefore, we include the costs of training the vidual smoker in the nonprepared categories, since the
additional physicians in our analysis. intervention is delivered during an opportunistic visit.
● On this basis, total costs for the workshops were Given the 2- and 4-min assumptions used above at an
estimated at $85,182, of which $30,927 (36.3%) was average hourly earning of $9.40 per hour, the 2,092
incurred by the organizers, and $54,234 (63.7%) by the precontemplative smokers would incur an opportunity
physicians in terms of travel and opportunity costs of cost of $655 by taking part in the intervention and the
attendance. We assume that the physicians who took 2,633 contemplative smokers, $1,649.
part in the evaluation incurred these costs in the ratio
of their number to total physician attendees at the ers is $2,305 for taking part in Smokescreen.
workshops (198/429), a total of $25,031. Prepared smokers incur the costs of an extra 0.296
● The total opportunity cost for nonprepared smok-

COST-EFFECTIVENESS ANALYSIS
645
TABLE 2
The Costs of Smokescreen
Bearers of cost
Smokers
Costs
Organizers
Physicians
Precontemplative
Contemplative
Prepared
Fixed costsa
Training
Smokescreen kit
Variable costsb
Training
$30,927
NA
NA
$13,180
NA
NA
NA
NA
NA
NA
NA
NA
$30,927
$25,031
$34,599
$72,810
NA
$655
$655
NA
$1,649
$1,649
NA
$23,429
$23,429
Intervention
Total costs
a
Fixed costs are those that remain static within a given discrete training program despite the number of physicians trained or patients
intervened with.
b Variable costs are those that vary as a function of the number of physicians or patients.
visits each on average, plus the initial 5-min consulta- robustness of our results it is conventional to subject
tion time. We assume they live on average within 30 such assumptions to a sensitivity analysis. There are
minutes round-trip of their physician’s office, have a three main sources of sensitivity in this study: the ex-
15-min wait and a 15-min consultation, a total of 1 h. clusion of existing variables; the alteration of existing
At the above rate this works out at a total opportunity variables; and the inclusion of new variables.
cost of $9.40 per visit. Travel costs are assumed to be
a further arbitrary $1.57 per visit.
● Therefore, each average prepared smoker incurs
an extra $3.24 in costs due to the intervention, $5,854
Exclusion of smokers for whom abstinence is not
known. Some may argue that it is not valid to extrapo-
late the effectiveness of Smokescreen outside of what
is strictly known. In other words we should limit the
for all prepared smokers. Adding in the extra 5-min
cost-effectiveness analysis to the “hard” evidence. Al-
consultation yields a total cost of $7,267.
though we do not share this view we estimate the im-
pact of it below. Restricting the analysis to those we
However, physicians also suggested that prepared
smokers used nicotine chewing gum as an aid to cessa-
“know” were abstinent (i.e., prepared smokers with
tion, adding to the costs of the intervention. It was
bookmarks who were followed-up), we assume that the
found that 26% of prepared smokers used gum at an
only abstainers were the 159 prepared smokers mea-
average rate of five pieces per day over a mean of 6
sured as such, adjusted down to 151 assuming a 95%
weeks during the treatment period, at a cost per 105-
chemical validation rate. Ignoring other smokers, this
leads to a gross quit rate of 15.7% and a net quit rate
of 7.7%, a total of 74 abstainers (assuming a spontane-
ous quit rate of 8% in prepared smokers as justified
piece packet of $17.
● Each average prepared smoker incurs an extra
$8.96 in costs due to nicotine gum use, $16,162 for all
prepared smokers. Therefore, total costs to prepared
above). The 95% confidence intervals around this are
smokers are $23,429 and summing across all smokers,
6.0 to 9.4%, implying only 58–91 additional abstainers
as a result of Smokescreen. Cost-effectiveness under
this conservative assumption from an organizer ’s point
of view is $421 (CI: $340–$533), from the physicians’
total costs are $25,734 per smoker.
Table 2 summarizes our cost estimates for Smoke-
screen.
perspective $984 (CI: $800–$1,255), the smokers’ per-
spective $348 (CI: $283–$444), and society’s point of
RESULTS
The Cost-Effectiveness of Smokescreen
view $1,749 (CI:$1,423–$2,233).
Initial cost-effectiveness estimates are reported in
Exclusion of training and workshop costs: A fairer
the second column of Table 3—labeled Baseline sce- comparison with other studies? One advantage of this
nario—from the perspectives of the organizer, the phy- study is the inclusion of the training and workshop
sicians, the smokers, and all parties. Cost-effectiveness costs, which makes the cost-effectiveness figures much
is defined as cost per additional abstainer due to the more realistic than most economic evaluations of smok-
Smokescreen intervention. Ninety-five percent confi- ing cessation [27]. However, including the full training
dence intervals based on the quit rate are also given.
costs of the intervention makes comparisons with other
programs difficult, since other economic evaluations
tend to neglect such costs. Workshop costs account for
Sensitivity Analysis
We have made several assumptions about the cost over 40% of total costs in our case, seriously disadvan-
and effectiveness of Smokescreen. In order to check the taging Smokescreen in relation to other previously

646
BUCK, RICHMOND, AND MENDELSOHN
TABLE 3
Variations in the Cost-Effectiveness of Smokescreen —Baseline, Optimistic, and Pessimistic Assumptions about Abstinence
Including training costs
Optimistic scenario
Excluding training costs
Optimistic scenario
Perspective
of
Baseline scenario
Pessimistic scenario
Baseline scenario
Pessimistic scenario
Cost per additional abstainer
$189 (CI:$164–$222) $0
$279 (CI:$249–$317) $135 (CI:$125–$147) $444 (CI:$385–$524) $183 (CI:$164–$208)
$99 (CI:$88–$112) $48 (CI:$44–$52) $157 (CI:$136–$185) $99 (CI:$88–$112)
Organizer
Physicians
Smokers
$118 (CI:$106–$134)
$57 (CI:$53–$63)
$0
$0
$88 (CI:$82–$97)
$48 (CI:$44–$52)
$291 (CI:$253–$344)
$157 (CI:$136–$185)
All parties
$496 (CI:$443–$563) $240 (CI:$222–$262) $789 (CI:$685–$931) $281 (CI:$252–$320) $137 (CI:$126–$149) $448 (CI:$389–$529)
costed interventions. Excluding workshop costs reduces with precontemplators and contemplators—and that
organizers costs to zero and the cost per additional ab- Smokescreen was utilized after the study period (88%
stainer from the perspective of smokers remains un- of physicians were still using it at 6 months post-follow-
changed. However, cost per additional abstainer falls up). Since we have little knowledge of the extent of
to $183 from the perspective of physicians and to $281 these effects through time, and we are focusing on the
from the perspective of all parties (column 4 of Table immediate costs and effectiveness of Smokescreen in
3—Baseline scenario, Excluding training costs). These this study, we have not taken them into account. How-
are the most relevant figures when judging Smoke- ever, these factors do suggest that our optimistic sce-
screen against other smoking cessation interventions. nario is not as optimistic as it might be.
Inclusion of all physicians attending the work-
shops. We have alluded to the 231 other physicians
who attended the training workshops but who were not
included in the original utilization study. Nevertheless,
these physicians may have benefited from the training
program and may be more effective in intervening with
their smoking patients. However, just how effective
they are over and above natural abstinence is unknown.
What is certain is that the overall costs to smokers
and physicians will rise with intervention, as will the
number of abstainers. From the organizers’ perspective,
cost-effectiveness will improve, since the fixed costs of
the workshop will be spread over more abstainers.
Overall, we would expect Smokescreen to be less effec-
tive among these physicians compared to those who
agreed to participate in our study, who were probably
more motivated. Therefore, cost per abstainer, based
on costs to all parties, may be higher than in our base-
line assumptions.
Changing the abstinence rate due to Smokescreen.
As the original Smokescreen study did not collect absti-
nence rates for nonprepared smokers nor assess the
natural abstinence rates for smokers in all categories,
we have had to extrapolate to derive the net effective-
ness of Smokescreen for these groups. In the optimistic
scenario, a better abstinence rate due to Smokescreen
is combined with a lower natural abstinence rate, re-
sulting in a net boost to the number of abstainers. In
the pessimistic scenario, the converse is the case.
Taking the optimistic scenario first, we assume that
all prepared smokers who missed follow-up, for what-
ever reason, have an abstinence rate of step 5 (see
Fig. 1). Further, their natural abstinence rate is identi-
cal to that of other smokers. For contemplative smokers,
the net effectiveness of Smokescreen is doubled while
Smokescreen leads to a net 2% gain in the number of
nonsmokers among precontemplators. This leads to a
rise in the number of abstinent smokers from 261 to
538. The impact on cost per additional abstainer is pre-
sented in Table 3, columns 3 and 6, respectively, de-
pending on the treatment of training costs.
DISCUSSION
Is Smokescreen cost-effective? The answer to this de-
In the pessimistic case we assume that Smokescreen pends on two things: how variable the estimates of cost
continues to have the same effect for prepared smokers per abstainer are and how these estimates compare to
we know nothing about, based on our conservative base- the cost-effectiveness of other smoking cessation inter-
line assumptions set out in Table 1. However, the natu- ventions and medical therapies. Different decisions
ral abstinence rate of ready smokers increases by 50 about the management of training costs and abstention
to 12% and the net effectiveness of Smokescreen for rates introduce some variability into the estimates of
contemplative smokers halves to 1.625%. This results cost-effectiveness. However, this spread seems reason-
in a drop in the number of abstinent smokers from 261 able, and we believe our pessimistic assumptions are
to 164. The impact on cost per additional abstainer is particularly strong. Including training costs increases
presented in Table 3, columns 4 and 7, respectively, the baseline cost per abstainer by 75% from the perspec-
depending on the treatment of training costs.
tive of all parties and also increases the spread of esti-
Finally, it should be noted that the Stages of Change mates on the basis of optimistic and pessimistic as-
model implies a delayed treatment effect —particularly sumptions about effectiveness.

COST-EFFECTIVENESS ANALYSIS
647
To judge whether Smokescreen is really worthwhile perspective of family physicians—since this has been
it is important to know what else could have been the focus of much published work. However, this de-
bought with those resources. There are now several pends on our assumptions about the effects of Smoke-
reviews of the general cost-effectiveness of smoking ces- screen outside the “hard” evidence about quitting and
sation interventions [10,27,31–38]. Comparing results Smokescreen —the net actual quitters among prepared
across types of intervention, settings, countries, and smokers. Assuming that noone else quits, this has the
time periods is always problematic. The present study effect of decreasing Smokescreen’s cost-effectiveness
is also different from other economic evaluations of substantially from $183 to $984 per additional ab-
smoking cessation programs. First, it is one of the few stainer. It is still cost-effective relative to worksite in-
that uses smoking patients who were not volunteers, terventions; however, it suffers in comparison with
or otherwise selected subjects. Second, it intervenes mass-media programs. Interestingly, Smokescreen is
differently with smokers according to their readiness more cost-effective from a societal point of view than a
to change. And third, it is only the second economic combined intervention using self-help manuals or
evaluation to our knowledge that includes training group programs as reported in the Dutch study [39] in
costs. For all these reasons it is complex to compare Table 4. This comparison is interesting because the
the cost-effectiveness of Smokescreen to other smoking Dutch study also included and excluded training and
cessation interventions. However, the cost-effectiveness set-up costs as part of the sensitivity analysis. Smoke-
of Smokescreen needs to be seen in some context. With screen is more cost-effective on a like-for-like basis.
the above caveats in mind Table 4 compares our results
Nonetheless the assumptions about abstention are
with a recent review by Warner [10] and other recent clearly crucial to the cost-effectiveness of Smokescreen.
studies. All costs were converted to 1995 U.S. dollars. Further studies of Smokescreen need to be undertaken
As can be seen from Table 4, the cost per abstainer to replace the need for assumptions with actual evi-
using Smokescreen is comparable to the cost-effective- dence. Clearly it would have been better to have de-
ness of a media program depending on the mix of as- signed the study with an economic evaluation compo-
sumptions. Under all baseline combinations Smoke- nent from its inception. Our findings illustrate the
screen is more cost-effective than a general worksite potential for retrospective cost-effectiveness analysis of
program. We present five combinations to illustrate smoking cessation interventions. Using existing data
how changes in our assumptions affect Smokescreen’s and conservative estimates of outcomes when required,
relative cost-effectiveness. The most comparable to pub- the Smokescreen smoking cessation program appears
lished figures is probably our lowest figure in the ta- to be reasonably cost-effective when compared to other
ble—baseline results excluding training costs from the smoking cessation interventions.
TABLE 4
Smokescreen Compared to Other Selected Smoking Cessation Interventions (1995 U.S. Dollars)
Cost per
quitter
Study and country
Population
Type of Intervention
($)
Australia: This study
Adult smokers visiting
physicians
Smokescreen program: Perspective of physicians excluding
training costs
183
Sweden: Tillgren et al. [36]
Australia: This study
Adults 16 years and over
Adult smokers visiting
physicians
Mass media
250
279
Smokescreen program: Perspective of physicians including
training costs
Australia: This study
Adult smokers visiting
physicians
Smokescreen program: Perspective of “all parties” excluding
training costs
281
Sweden: Tillgren et al. [36]
Australia: This study
Adults 16 years and over
Adult smokers visiting
physicians
Mass media ϩ county level organizational strategy
Smokescreen program: Perspective of “all parties” including
training costs
290
496
Netherlands: Mudde et al. [39]
Australia: This study
Adult smokers
Self-help manual and group program. Perspective “all parties”
including training costs. Optimistic quit assumptions
based on confidence intervals
Smokescreen program: Perspective of physicians excluding
training costs and using only “hard” evidence of
abstinence
743
984
Adult smokers visiting
physicians
Netherlands: Mudde et al. [39]
Adult smokers
Self-help manual and group program. Perspective “all parties”
including training costs. Pessimistic quit assumptions
based on confidence intervals
1,487
1,500
U.S.: McGhan et al. [37]
Blue-collar workers
Worksite smoking cessation program
Source: Collated from Warner [10] and authors’ conversion of our study results to 1995 U.S. dollars, as described in text.

648
BUCK, RICHMOND, AND MENDELSOHN
18. Richmond R, Webster I. Become a non smoker. Sydney: Octopus
ACKNOWLEDGMENTS
Books, 1988.
David Buck was a research fellow at the Centre for Health Econom-
ics, University of York, U.K., during the early stages of the current
project. He acknowledges and is grateful for non-financial support.
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