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BACKGROUND AND AIMS: Although clear benefits are associated with reducing smoking, there is increasing pressure on public health providers to justify investment in tobacco control measures. Decision makers need tools to assess the return on investment (ROI)/cost effectiveness of programs. The EQUIPT project adapted an ROI tool for England to four European countries (Germany, Netherlands, Spain and Hungary). EQUIPTMOD, the economic model at the core of the ROI tool, is designed to assess the efficiency of packages of smoking cessation interventions. The objective of this paper is to describe the methods for EQUIPTMOD and identify key outcomes associated with continued and cessation of smoking. METHODS: EQUIPTMOD uses a Markov model to estimate lifetime costs, quality adjusted life years (QALYs) and life years associated with a current and former smoker. It uses population data on smoking prevalence, disease prevalence, mortality and the impact of smoking combined with associated costs and utility effects of disease. To illustrate the tool’s potential, costs, QALYs and life expectancy were estimated for the average current smoker for five countries based on the assumptions that they continue and that they cease smoking over the next 12 months. Costs and effects were discounted at country specific rates. RESULTS: For illustration, over a lifetime horizon, not quitting smoking within the next 12 months in England will reduce life expectancy by 0.66, reduce QALYs by 1.09 and result in £4,961 higher disease related health care costs - than if the smoker ceased smoking in the next 12 months. For all age-sex categories, costs were lower and QALYs higher for those who quit smoking in the twelve months than those who continued. CONCLUSIONS: EQUIPTMOD facilitates assessment of the cost effectiveness of smoking cessation strategies. The demonstrated results indicate large potential benefits from smoking cessation at both an individual and population level.

Aims To evaluate costs, effects and cost-effectiveness of increased reach of specific smoking cessation interventions in Germany. Design A Markov-based state transition return on investment model (EQUIPTMOD) was used to evaluate current smoking cessation interventions as well as two prospective investment scenarios. A health-care perspective (extended to include out-of-pocket payments) with life-time horizon was considered. A probabilistic analysis was used to assess uncertainty concerning predicted estimates. Setting Germany. Participants Cohort of current smoking population (18+ years) in Germany. Interventions Interventions included group-based behavioural support, financial incentive programmes and varenicline. For prospective scenario 1 the reach of group-based behavioral support, financial incentive programme and varenicline was increased by 1% of yearly quit attempts (= 57915 quit attempts), while prospective scenario2represented a higher reach, mirroringthe levels observed inEngland. Measurements EQUIPTMOD considered reach, interventioncost, number of quitters, quality-of-lifeyears (QALYs) gained, cost-effectivenessand returnon investment. Findings The highest returns throughreduction insmoking-related health-care costswere seen for the financial incentive programme ((sic)2.71 per (sic)1 invested), followed by that of group-based behavioural support ((sic)1.63 per (sic)1 invested), compared with no interventions. Varenicline had lower returns ((sic)1.02 per (sic)1 invested) than the other two interventions. At thepopulationlevel, prospective scenario1led to15 034QALYsgained and (sic)27millioncost-savings, compared with current investment. Intervention effects and reach contributed most to the uncertainty around the return-oninvestment estimates. At a hypothetical willingness-to-pay threshold of only (sic)5000, the probability of being cost-effective is approximately 75% for prospective scenario 1. Conclusions Increasing the reach of group-based behavioural support, financial incentives and varenicline for smoking cessation by just 1% of current annual quit attempts provides a strategy to German policymakers that improves the population's health outcomes and that may be considered cost-effective.

© 2015 The Authors. Aims This paper provides a concise review of the efficacy, effectiveness and affordability of healthcare interventions to promote and assist tobacco cessation, in order to inform national guideline development and assist countries in planning their provision of tobacco cessation support. Methods Cochrane reviews of randomised controlled trials (RCTs) of major healthcare tobacco cessation interventions were used to derive efficacy estimates in terms of percentage-point increases relative to comparison conditions in 6–12 month continuous abstinence rates. This was combined with analysis and evidence from ‘real world’ studies to form a judgement on the likely effectiveness of each intervention in different settings. The affordability of each intervention was assessed for exemplar countries in each World Bank income category (low, lower middle, upper middle, high). Based on WHO criteria, an intervention was judged as affordable for a given income category if the estimated extra cost of saving a life-year was less than or equal to the per-capita Gross Domestic Product for that category of country. Results Brief advice from a healthcare worker given opportunistically to smokers attending healthcare services can promote smoking cessation and is affordable for countries in all World Bank income categories (i.e., globally). Proactive telephone support, automated text messaging programmes, and printed self-help materials can assist smokers wanting help with a quit attempt and are affordable globally. Multi-session, face-to-face behavioural support can increase quit success for cigarettes and smokeless tobacco and is affordable in middle and high income countries. Nicotine replacement therapy, bupropion, nortriptyline, varenicline and cytisine can all aid quitting smoking when given with at least some behavioural support; of these cytisine and nortriptyline are affordable globally. Conclusions Brief advice from a healthcare worker, telephone helplines, automated text messaging, printed self-help materials, cytisine and nortriptyline are globally affordable healthcare interventions to promote and assist smoking cessation. Evidence on smokeless tobacco cessation suggests that face-to-face behavioural support and varenicline can promote cessation. This article is protected by copyright. All rights reserved.

Introduction: Tobacco smoking claims 700 000 lives every year in Europe and the cost of tobacco smoking in the EU is estimated between €98 and €130 billion annually; direct medical care costs and indirect costs such as workday losses each represent half of this amount. Policymakers all across Europe are in need of bespoke information on the economic and wider returns of investing in evidence-based tobacco control, including smoking cessation agendas. EQUIPT is designed to test the transferability of one such economic evidence base—the English Tobacco Return on Investment (ROI) tool—to other EU member states. Methods and analysis: EQUIPT is a multicentre, interdisciplinary comparative effectiveness research study in public health. The Tobacco ROI tool already developed in England by the National Institute for Health and Care Excellence (NICE) will be adapted to meet the needs of European decision-makers, following transferability criteria. Stakeholders’ needs and intention to use ROI tools in sample countries (Germany, Hungary, Spain and the Netherlands) will be analysed through interviews and surveys and complemented by secondary analysis of the contextual and other factors. Informed by this contextual analysis, the next phase will develop country-specific ROI tools in sample countries using a mix of economic modelling and Visual Basic programming. The results from the country-specific ROI models will then be compared to derive policy proposals that are transferable to other EU states, from which a centralised web tool will be developed. This will then be made available to stakeholders to cater for different decision-making contexts across Europe. Ethics and dissemination: The Brunel University Ethics Committee and relevant authorities in each of the participating countries approved the protocol. EQUIPT has a dedicated work package on dissemination, focusing on stakeholders’ communication needs. Results will be disseminated via peer-reviewed publications, e-learning resources and policy briefs. info:eu-repo/semantics/acceptedVersion