Cost-effectiveness of smoke-free interventions: A systematic review

Tobacco use imposes substantial global economic costs - estimated at $1803 to $1899 billion annually (1.76-1.85% of global gross domestic product) - through healthcare expenditures and productivity losses. In 2019, it contributed to approximately 8.70 million deaths and 229.77 million disability-adjusted life years (DALYs); secondhand smoke exposure added 1.31 million deaths and 37.01 million DALYs. While tobacco control efforts continue, evidence on the economic impacts of interventions remains limited. This study systematically reviews the cost-effectiveness of smoke-free interventions to inform policy.

A systematic literature review was conducted following PRISMA guidelines and registered with PROSPERO (CRD42024521198). Searches conducted in January 2024 in PubMed, Web of Science, and Cochrane databases identified English-language economic evaluations of smoke-free interventions. Data were extracted using pre-defined checklists, and results were summarized using narrative synthesis. Studies were further assessed using the Consensus Health Economic Criteria (CHEC) and Consolidated Health Economic Evaluation Reporting Standards (CHEERS) tools. Studies scoring <60% on CHEERS were excluded.

Of 639 articles, 9 met the inclusion criteria. Most used healthcare or government perspectives (56%), 33% adopting a societal perspective. Interventions included public (44%), workplace, and school-based smoking bans. Studies were conducted in Vietnam, the US, Indonesia, Tanzania, Estonia, Denmark, India, and EU countries, employing economic models such as Markov models (44%). Time horizons ranged from one year to lifetime. Incremental cost-effectiveness ratios (ICERs) ranged from $7 per DALY averted to $17056 per life year gained. Most interventions were found to be cost-effective or dominant.

Public smoking bans consistently saved healthcare costs; workplace and school-based bans were also cost-effective, though context-dependent. This review suggests that smoking bans, particularly comprehensive smoke-free policies, should be prioritized by decision-makers as they demonstrate both health and economic benefits, proving to be cost-effective or even cost-saving public health interventions.