Date of Award


Document Type


Degree Name

Doctor of Philosophy (PhD)


Health Science Administration

Research Advisor

Robert C. Klesges, PhD.


Joni Hersch, PhD Song Hee Hong, PhD Junling Wang, PhD Shelley White-Means, PhD


Cost-effectiveness analysis, Nicotine replacement therapy, Smoking cessation, Stepped care


It has been well established that smoking is the leading avoidable cause of premature morbidity and mortality in the United States and abroad. Smoking is attributable to over 400,000 annual deaths, and $193 billion in healthcare costs and lost productivity. Despite the apparent dangers and tremendous costs of tobacco use and dependence, smokers find difficulty quitting. Recently, stepped care has been proposed as a viable intensive approach for achieving long-term cessation. This research sought to evaluate cost-effectiveness of stepped care in a diverse population of smokers and analyze future health outcomes of smoking cessation.

Cost-effectiveness analysis was conducted from an institutional perspective alongside an NIH-funded multi-site study, “Long-term Smoking Cessation Using Prescription Step Care” (STEP), which compared stepped care to a repeat care intervention. The outcome of interest was incremental cost per quit achieved by stepped care. Secondly, long-term cost-effectiveness of successful smoking cessation was analyzed using a societal perspective. A microsimulation model was developed to predict changes in morbidity and mortality over the lifetime for four smoking-related diseases (ischemic heart disease, cerebrovascular disease, lung cancer, and emphysema) due to successful cessation. Here, the outcome of interest was incremental cost per quality-adjusted life year due to successful cessation. Lastly, sensitivity analyses were conducted to gauge robustness of estimates.

In the STEP study, costs for stepped versus repeat care were $875.09 and $422.26, respectively. Point-prevalence abstinence was validated among 20.5% (versus 22.5%) of stepped care patients; continuous abstinence was achieved by 11.9% (versus 14.3%) of stepped care patients. Stepped care was dominated by repeat care, being more costly but less effective. Stepped care produced a favorable incremental cost-effectiveness ratio only among women achieving continuous abstinence in the Mayo sample. All other scenarios favored repeat care. When future outcomes of cessation were analyzed, average costs in original versus amended analyses were $49,025 and $48,956, respectively; QALYS gained were 8.62 and 8.6, for the aforementioned analyses. Successful cessation yielded incremental cost-effectiveness of $3,450 per QALY. In sensitivity analysis, incremental cost-effectiveness varied from cost-saving to $13,700 per QALY.

Stepped care was not cost-effective relative to repeat intervention. Quitting at the UTHSC site and among ethnic minorities was low, despite better rates of participation. Higher depression scores may have attributed to these results. Success of repeat care in STEP affirms findings of two recent studies. However, long-term cessation did prove highly cost-effective. Smoking cessation interventions continue to be extremely cost-effective and provide sizable returns on investment to employers and payers alike; enhanced coverage of smoking cessation treatments and programs will likely increase quit attempts and ultimately, cessation.