Editorial for “COST-EFFECTIVENESS OF POINT OF CARE SMOKING CESSATION INTERVENTIONS IN ONCOLOGY CLINICS’ by Meullan et al.

Smoking tobacco causes at least 20 types of cancer, and stopping smoking reduces the risk of developing these cancers. However, around 12% of all cancer patients, and as high as 25–50% of patients with lung cancer still smoke at the time of a cancer diagnosis. Continued smoking can affect the proliferation, migration, and invasion of tumour cells, impair the immune response, worsen the outcomes of cancer treatments, and accelerate other illnesses, in cancer patients [1]. Stopping smoking at the time of a cancer diagnosis is crucial, as it can extend median survival by 2–3 years and lower the risk of death by 30–50% [2, 3]. Despite these substantial benefits, the treatment of tobacco dependency is not routinely integrated into cancer care. Whilst some tobacco cessation treatment programmes in cancer care exist, like the Cancer Centre Cessation Initiative (C3I, a group of cancer centres providing independent tobacco treatment programmes) in the United States [4], and the Ottawa Model for Smoking Cessation in Canada [5], up to 70% of oncologists in these countries feel inadequately trained in tobacco dependency, and only 40% actively provide or refer patients for support and treatment [6]. The situation is worse in low- and middle-income countries (LMICs), where tobacco cessation treatment is rarely part of cancer care, and fewer than half of cancer patients who smoke receive brief advice regarding stopping smoking [7]. Studies are needed to identify barriers to implementing tobacco cessation support in cancer services across both LMICs and high-income countries, where challenges may vary. However, economic and cost-effectiveness considerations are crucial for policymakers and healthcare payers in each country when deciding on these programmes.

The study by Mullen et al. is one of the few that assessed the cost-effectiveness of implementing two tobacco dependency treatment models in cancer clinics compared to usual care with no treatment service [8]. The first model, the Ottawa Model for Smoking Cessation (OMSC), has been implemented since 2016 in the oncology clinics of New Brunswick, Canada. This model includes systematically identifying all patients that actively smoke tobacco and, on an opt-out basis, providing those patients with brief practical advice, prescribing stop-smoking pharmacotherapy, providing written information on the effects of smoking on cancer treatment, and offering telephone follow-up support with motivational messaging and access to specialist advisors. This study found that the OMSC model, despite minimal additional costs (primarily personnel cost), led to significant clinical benefits, such as lower treatment failure rates and a higher number of patients successfully abstinent from tobacco. These benefits resulted in annual savings of $386,919 to $1,055,984 compared to no cessation treatment, with a return on investment (ROI) between 282 and 771%. Another strength of this study is its assessment of the cost-effectiveness of providing cost-free stop-smoking medication (SSM), including nicotine replacement therapy (NRT), varenicline, or bupropion, along with more intensive follow-up calls by physicians as part of the OMSC programme. The results show that the OMSC + SSM model is even more cost-effective, with fewer treatment failures and a higher number of patients successfully abstinent from tobacco compared to both usual care and the OMSC model alone. Additionally, adding SSM to the OMSC model reduced the number needed to treat to avoid one treatment failure (45 vs. 78) and to produce one quit (4 vs. 9). Implementing the OMSC + SSM model in oncology clinics was estimated to save between $665,227 and $1,683,518 annually, with a ROI ranging from 486 to 1229%. These results are particularly important for LMICs, where the cost of effective SSM continues to be a major barrier to delivering effective tobacco dependency treatment.

The benefits and cost-effectiveness of implementing tobacco dependency treatment on cancer care is almost certain to be substantially greater than what is calculated in this paper due to several methodological limitations that will have led to an underestimation of the effects of smoking cessation interventions. First, the study estimated treatment failure at 52% for patients who continued smoking and 40% for those who quit, based on a previous modelling study. These estimates may be conservative because up to 30% of cancer patients who smoke might be reluctant to disclose their smoking habits at diagnosis [9]. Furthermore, these estimates did not account for changes in smoking status after diagnosis, which can significantly impact tumour progression and survival probability. Second, the study assessed costs and benefits over just one treatment year, while long-term evidence (e.g., 5 years post-diagnosis) indicates that stopping smoking offers even greater benefits, in higher survival proportions and lower risk of tumour progression [2, 3]. Furthermore, the study evaluated the effects of stopping only within the first 6 months post-diagnosis, whereas stopping smoking even after this period has been shown to be beneficial for patients with cancer. Third, the study considered cost-effectiveness mainly in terms of treatment failure, whereas continued smoking may also increase the risk of non-cancer mortality, hospitalization, toxic effects from cancer treatment, and the likelihood of a second primary cancer, all of which can lead to additional costs [10]. Furthermore, continued smoking vs, stopping smoking after cancer diagnosis can shorten the overall and progression-free survival time by an average 2–3 years [2, 3]. All these factors can significantly impact metrics like years of life lost (YLL), disability-adjusted life years (DALYs), and productivity and disability costs, thereby posing a substantial economic burden on the healthcare system. While this study makes a strong case for action, cost-effectiveness analyses are needed in other countries due to differences in healthcare infrastructure, facilities, and the cost of smoking cessation medications. This is particularly important for LMICs, as approximately 80% of people who use tobacco live in these countries.

The OMSC should be recognised for its contribution to the global efforts to reduce the substantial burden caused by tobacco. It was the OMSC within acute care Hospitals that influenced health policy in the UK. Data published by Mullen et al in 2016 reported a reduction in 1-year mortality from 11.4 to 5.4% (p < 0.001) and a reduction in readmission rates at 1 year from 38.4 to 26.7% (p < 0.001) in patients admitted to hospital who smoked, where systematic identification and opt-out treatment, as described above, were implemented [5]. In its 2018 report ‘Hiding in plain sight: treating tobacco dependency in the NHS’, the Royal College of Physicians used these relative risk reductions to calculate that the NHS in England could save £60 million per year in healthcare utilisation costs if the OMSC was implemented at scale across acute care trusts in England. In 2019, the NHS long term plan committed that ‘by 2023/2024 all patients admitted to hospital that smoke will be offered NHS funded tobacco treatment services’ [11]. Following this there has been a rapid proliferation of hospital-based tobacco dependency treatment services making this a new standard of care in the UK. The OMSC has, therefore, already served as a good example where evidence can be used to drive healthcare policy for an unmet need. The publication of this current work on treating tobacco dependency within cancer care must be seen as a further opportunity to drive healthcare policy in an area where tobacco dependency treatment is limited and there are substantial missed opportunities to improve outcomes and healthcare utilisation.

Where authors are identified as personnel of the International Agency for Research on Cancer / World Health Organization, the authors alone are responsible for the views expressed in this article and they do not necessarily represent the decisions, policy or views of the International Agency for Research on Cancer / World Health Organization.