Cost-effectiveness of tobacco control strategies towards youths across seven European countries: Measurement, challenges and results

Abstract

Background Tobacco consumption among adolescents is a major public health concern as it is highly related to smoking addiction in adulthood and, thus, to morbidity and premature mortality. In order to reduce smoking prevalence and its consequences, tobacco control strategies targeting adolescents have been suggested, but only a few have been fully implemented at a large scale. This insufficient implementation is, in part, linked to the concern that some strategies have a high implementation cost, not compensated by their effectiveness. In this study we aimed at estimating the costs and cost-effectiveness of five smoking prevention strategies targeting adolescents (bans on smoking in public places, bans on sales to minors, bans on point-of-sale advertising, bans on smoking at school premises, and school prevention programs), across seven European countries (Finland, Ireland, Netherlands, Belgium, Germany, Italy, and Portugal) in 2016. Methods We retrospectively collected costs related to (1) the inspection activities and legal procedures related to public bans, (2) the monitoring of school bans and sanctioning of non-compliant students, and (3) school-based education activities related to smoking prevention programs. We used an “ingredients-based” approach, identifying each resource used, quantity and unit value for one full year, under the State perspective. Annual costs were measured at national, local, or school-level, for the year 2016 and were complemented with qualitative data on how these activities were performed in reality, through interviews to key informants at the school, local, regional, and national level. The effectiveness was estimated using the DYNAMO-HIA tool, departing from data on short-term smoking prevalence reduction, collected from the literature. The simulation followed the whole population of each of the seven countries, since year 0 until when the last person of the cohort died, estimating the number of healthy life years (HLY) gained by each intervention, comparing with a no-intervention scenario. The HLY were calculated using estimates for the relationship between smoking and several diseases, as ischemic heart disease, stroke, chronic obstructive pulmonary disease and lung, oral, oesophageal, breast and colorectal cancer and for the relationship between these diseases and mortality. Baseline data was adapted to each country, using country-specific epidemiological data. Long-term costs were obtained by multiplying annual cost estimates for a 17-years’ time horizon, in order to reflect the total number of years of implementation for the cohort (to cover all groups that have 0 to 17 years old at year 0). Costs were discounted at a 3.5% annual rate. Results Costs varied between from € 0.07 to € 1.08 per person for public non-school bans, from € 2.28 to € 29.06 for school bans and from € 0.17 to € 3.16 for school programmes, according to the number of person-hours allocated to the implementation of these strategies. Italy was the country with the smallest annual investment on these tobacco-control strategies (€ 2.84 per person), while Ireland had the highest (€ 29.77 per person). Effectiveness estimates ranged from 0.003 HLY gained per person in Portugal, for a 1% short-term relative reduction of smoking prevalence, to 0.39 HLY in Ireland, for a 50% reduction. Public non-school bans were be the most cost-effective interventions, with € 0.18 to € 399.21 per HLY. School bans costed from € 173.41 to € 4315.78 per HLY, and school programmes from € 9.66 to € 11015.38 per HLY. Conclusions These five smoking prevention strategies targeting adolescents are low cost and, considering the WHO cost-effectiveness threshold ratio of each country GDP per capita, highly cost-effective interventions. Hence, investing in tobacco control strategies targeting adolescents may be an economically advantageous approach to tackle one of the main causes of mortality and morbidity in Western Europe.