Healthcare financing systems for increasing the use of tobacco dependence treatment

Ayalu A Reda, Daniel Kotz, Silvia M.A.A Evers, Constant Paul van Schayck

Cochrane Database of Systematic Reviews 2012, Issue 6. Art. No.: CD004305. DOI: 10.1002/14651858.CD004305.pub4

Background
We hypothesized that provision of financial assistance for smokers trying to quit, or reimbursement of their care providers, could lead
to an increased rate of successful quit attempts.

Objectives
The primary objective of this review was to assess the impact of reducing the costs of providing or using smoking cessation treatment
through healthcare financing interventions on abstinence from smoking. The secondary objectives were to examine the effects of
different levels of financial support on the use and/or prescription of smoking cessation treatment and on the number of smokers
making a quit attempt.

Search methods
We searched the Cochrane Tobacco Addiction Group Specialized Register in April 2012.

Selection criteria
We considered randomised controlled trials (RCTs), controlled trials and interrupted time series studies involving financial benefit
interventions to smokers or their healthcare providers or both.

Data collection and analysis
Two reviewers independently extracted data and assessed the quality of the included studies. Risk ratios (RR) were calculated for
individual studies on an intention-to-treat basis and meta-analysis was performed using a random-effects model. We included economic
evaluations when a study presented the costs and effects of two or more alternatives.

Main results
We found eleven trials involving financial interventions directed at smokers and healthcare providers.
Full financial interventions directed at smokers had a statistically significant favourable effect on abstinence at six months or greater
when compared to no intervention (RR 2.45, 95% CI 1.17 to 5.12, I² = 59%, 4 studies). There was also a significant effect of full
financial interventions when compared to no interventions on the number of participants making a quit attempt (RR 1.11, 95% CI
1.04 to 1.32, I² = 15%) and use of smoking cessation treatment (NRT: RR 1.83, 95% CI 1.55 to 2.15, I² = 43%; bupropion: RR
3.22, 95% CI 1.41 to 7.34, I² = 71%; behavioural therapy: RR 1.77, 95% CI 1.19 to 2.65). There was no evidence of an effect on
smoking cessation when we pooled two trials of financial incentives directed at healthcare providers (RR 1.16, CI 0.98 to 1.37, I² =
0%). Comparisons of full coverage with partial coverage, partial coverage with no coverage, and partial coverage with another partial
coverage intervention did not detect significant effects. Comparison of full coverage with partial or no coverage resulted in costs per
additional quitter ranging from $119 to $6450.

Authors’ conclusions
Full financial interventions directed at smokers when compared to no financial interventions increase the proportion of smokers who
attempt to quit, use smoking cessation treatments, and succeed in quitting.  The absolute differences are small but the costs per
additional quitter are low to moderate. We did not detect an effect on smoking cessation from financial incentives directed at healthcare
providers. The methodological qualities of the included studies need to be taken into consideration when interpreting the results.

P L A I N   L A N G U A G E   S U M M A R Y
Do interventions that reduce the cost of smoking cessation treatment increase quit rates, quit attempts or use of treatments?

Apart from providing counselling and drug treatment, strategies that reduce or cover the costs of accessing or providing these treatments
could help smokers quit.

We found eleven trials, eight of which involve financial interventions directed at smokers and three of which involve financial inter-
ventions directed at healthcare providers.

Covering all the costs of smoking cessation treatment for smokers when compared to providing no financial benefits increased the
proportion of smokers attempting to quit, using smoking cessation treatments, and succeeding in quitting. Although the absolute
differences in quitting were small, the costs per person successfully quitting were low or moderate. Financial incentives directed at
healthcare providers did not have an effect on smoking cessation.

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