Markov-model cost-effectiveness evaluation of a cessation programme when tobacco policies are comprehensive

This study conducts a cost-effectiveness analysis of the Tobacco Treatment Programme (TTP) of Uruguay's National Resource Fund (NRF), within the context of the country's advanced implementation of tobacco control policies.

We run a 10 000 Markov model simulation with three states (people who smoke, people who have quit smoking and death) to simulate the trajectories of a cohort. The model has been widely used in previous studies evaluating smoking cessation interventions.

For the simulations, we use information from the 2016 to 2017 NRF TTP cohort. Nearly half of the participants lived in the capital, one-fifth had tertiary education, and about one-third had public health coverage. Participants began smoking at an average age of 16 years and smoked about 20 cigarettes per day when entering the TTP.

The process of tobacco cessation is simulated under different alternatives: no intervention, the current TTP (bupropion, nicotine gum and counselling), an expanded TTP that incorporates nicotine patches as a replacement therapy, and a potential future programme with cytisine and counselling (with and without mortality adjustments).

We focus on Uruguay, which has been recognised as a global leader in tobacco control, including 100% smoke-free environments, a full advertising ban, plain packaging and steady tax increases.

We compare cost-effectiveness of policy alternatives using years of life lost (YLL) and incremental cost-effectiveness ratios, comparing policy alternatives with no intervention and the current tobacco cessation programme in the country. The analysis considers the direct costs of treatments for smoking-related diseases (healthcare perspective) as well as social costs resulting from loss of productivity (societal perspective).

The results indicate that all policy interventions lead to a reduction in the YLL compared with no intervention. Among these options, the inclusion of cytisine emerges as the most cost-effective choice. In a scenario including the transition probabilities from the TTP cohort, this alternative would result in a 10.9% reduction in YLL, with a particularly positive impact among women (-16.5% vs -4.0% in men). In terms of cost-effectiveness, the costs per YLL averted would be on average US$3991 per YLL from a healthcare perspective, and US$3773 per YLL from a societal perspective.

Tobacco cessation programmes in Uruguay are highly cost-effective, and our results justify their expansion and optimisation. The incorporation of cytisine into the TTP and a focus on groups with more severe tobacco consumption are recommended.