Chapter 5 The Benefits of Smoking Cessation on Overall Morbidity, Mortality, and Economic Costs Introduction 439 Benefits of Smoking Cessation on Overall Morbidity 439 Conclusions from Previous Surgeon General’s Reports 439 Description of the Literature Review 440 Assessment of Morbidity 440 Assessment of Smoking Status 440 Epidemiologic Evidence 457 Cross-Sectional Studies 457 Longitudinal Studies 458 Synthesis of the Evidence 460 Summary of the Evidence 460 Benefits of Smoking Cessation on All-Cause Mortality 461 Conclusions from Previous Surgeon General’s Reports 461 Summary of the Evidence 464 Benefits of Smoking Cessation on Economic Costs 465 Economic Costs of Smoking 465 Economics of Smoking Cessation 466 Principles of Cost-Benefit and Cost-Effectiveness Analysis 467 Cost-Effectiveness of Clinical Smoking Cessation Interventions 467 Cost-Effectiveness of Nonclinical Smoking Cessation Interventions 482 Cost-Effectiveness of Tobacco Price Increases Through Taxation 482 Synthesis of the Evidence 482 Summary of the Evidence 485 Conclusions 485 References 486 437 Smoking Cessation Introduction Cigarette smoking causes multiple diseases and mortality, and economic costs. Initially, it considers how reduces the general level of health of smokers (U.S. general indicators of health can change after smoking ces- Department of Health and Human Services [USDHHS] sation. This type of information is critical to informing 2004, 2014). These health consequences have been well smokers about the potential benefits of cessation and serves documented in previous Surgeon General’s reports. The as a strong rationale to provide interventions that can 1964 report first summarized results on smoking and all- help increase the success of quitting smoking. Such pro- cause mortality, finding that smoking causes a 70% increase grams may be offered through healthcare organizations, in risk of adverse health consequences (U.S. Department communities, states, and other organizations. Smoking is of Health, Education, and Welfare [USDHEW] 1964). The known to generate healthcare and other economic costs 2004 report found smoking generally diminishes health and to affect the economics of the households of smokers (USDHHS 2004). General measures of health can be infor- (USDHHS 2014). Previous Surgeon General’s reports on mative because they provide an integrative indicator of the tobacco have periodically reviewed the economic costs of health burden placed on smokers and on society overall. smoking, as tracked by the Centers for Disease Control In addition to the direct human costs that smoking places and Prevention’s (CDC’s) Smoking-Attributable Mortality, on persons and society, one general measure with acknowl- Morbidity, and Economic Costs (SAMMEC) model. This edged implications for public health policy and practice is chapter expands on this work by focusing on the most the economic cost of smoking. recently available scientific literature on the economic ben- This chapter considers broad indicators of burden efits of smoking cessation, while also complementing the in relation to smoking cessation, including morbidity, kinds of cost estimates previously provided by SAMMEC. Benefits of Smoking Cessation on Overall Morbidity Chapter 4 of this report (The Health Benefits of used in previous Surgeon General’s reports on smoking, Smoking Cessation) describes the associations between including the 2014 Surgeon General’s report (USDHHS smoking cessation and changes in risk for specific dis- 2014). However, to limit the scope of this review, some of ease outcomes. It also addresses how cessation affects the the many correlates of well-being (e.g., absenteeism from natural history of various disease outcomes, such as by work) are not specifically considered. slowing the progression of underlying pathophysiological processes. In addition to the beneficial impacts on spe- cific disease outcomes, previous reviews of smoking ces- Conclusions from Previous Surgeon sation and morbidity (Goldenberg et al. 2014) have con- General’s Reports cluded that cessation is associated with improvement in health-related quality of life (HRQoL), a broad construct Previous Surgeon General’s reports (USDHHS 1990, defined by Healthy People 2020 as “a multi-dimensional 2004) have comprehensively covered the relationship concept that includes domains related to physical, mental, between smoking and general morbidity. The 1990 Surgeon emotional, and social functioning” (Office of Disease General’s report on the health benefits of smoking cessa- Prevention and Health Promotion 2018). In a complemen- tion synthesized scientific evidence about cessation and tary conclusion, after evaluating a broad range of general its effects on general morbidity, concluding that “former evidence, the 2004 Surgeon General’s report concluded smokers have better health status than current smokers that active smoking is causally associated with diminished as measured in a variety of ways, including days of illness, health status (USDHHS 2004). number of health complaints, and self-reported health This chapter addresses the evidence on smoking status” (USDHHS 1990, p. 9). However, that report also cessation and its relationship to more general mea- found that the reviewed studies were “extremely heteroge- sures of health outcomes, particularly whether cessation neous, with some methodologic shortcomings” (USDHHS improves general QoL compared with continued smoking. 1990, p. 89) and that the “variety of measures used makes This review aligns with and complements the approach direct comparison across studies problematic” (USDHHS The Benefits of Smoking Cessation on Overall Morbidity, Mortality, and Economic Costs 439 A Report of the Surgeon General 1990, p. 87). The 2004 Surgeon General’s report on the Assessment of Morbidity health consequences of active smoking subsequently The general measures of morbidity used in the reviewed studies that included various indicators of gen- 24 identified studies varied but cover three main catego- eral health, concluding that “the evidence is sufficient to ries: general, smoking specific, or disease specific: infer a causal relationship between smoking and dimin- ished health status that may be manifest as increased 1. General. Many studies used general measures of absenteeism from work and increased use of medical care HRQoL, most frequently the Short Form (SF)-36 services” (USDHHS 2004, p. 676). In addition, a major (SF-36) and SF-12 surveys, both the Medical conclusion of the 2004 report was that “quitting smoking Outcomes Study (Ware Jr and Sherbourne 1992) has immediate as well as long-term benefits, reducing and RAND versions (Hays and Morales 2001). One risks for diseases caused by smoking and improving health study (Mitra et al. 2004) adapted the SF-36 for use in general” (USDHHS 2004, p. 25). The present chapter in a population with mobility impairments. The updates these findings on the basis of more recent studies other generic measures of HRQoL included the 15-D of smoking cessation and indicators of general morbidity. (dimensional) (Sintonen 1995), the EuroQoL (The EuroQol Group 1990), the QoL Inventory (Frisch et al. 1992), the World Health Organization’s QOL- Description of the Literature Review BREF (Skevington et al. 2004), CDC’s HRQOL-4 and its Healthy Days Symptoms Module (Moriarty et al. Scientific literature from 1990 to 2017 was system- 2003), and the Functional Status Questionnaire atically reviewed, and reference lists from the identified (Jette et al. 1986). The studies identified in the lit- articles were searched for additional studies. Search terms erature review also assessed dissatisfaction with life included “smoking cessation,” “epidemiology,” “mor- and general health status. bidity,” “health status,” and “quality of life.” Studies were included if they measured the benefit of smoking cessa- 2. Smoking specific. One study (Olufade et al. 1999) tion for general morbidity in former cigarette smokers; used the Smoking Cessation Quality of Life (SCQoL) thus, the appropriate comparison group was continuing questionnaire. cigarette smokers but not never smokers. Accordingly, only studies that specifically and directly compared out- 3. Disease specific. Some studies used disease-specific comes between former cigarette smokers (defined in measures of HRQoL. These measures assess the multiple ways) and current cigarette smokers were con- impact of specific diseases on relevant components sidered. Studies that included former cigarette smokers of QoL. The European Organisation for Research and but used only never smokers as the reference group were Treatment of Cancer (EORTC) QoL Questionnaire not included because such studies were not informative QLQ-C30 (Aaronson et al. 1993) was used, along with for the purpose of this chapter. However, when informa- the LC13 module for lung cancer (Bergman et al. tive comparisons were made in eligible studies that met 1994) and the H&N35 module for head and neck the criterion of comparisons with current smokers, some cancer (Bjordal et al. 1994). Other disease-specific findings for never smokers were included. instruments included the Aquarel questionnaire for Following the systematic review of literature, patients with pacemakers (Stofmeel et al. 2001), the 24 studies published from 1995 to 2016 were identified Clinical COPD Questionnaire (van der Molen et al. that assessed smoking cessation and general morbidity, 2003), and the VascuQoL questionnaire for patients including 7 cross-sectional studies (Table