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Cost-effectiveness of a School-Based Tobacco-Use Prevention Program
Li Yan Wang, MBA, MA;
Linda S. Crossett, RDH;
Richard Lowry, MD, MS;
Steve Sussman, PhD;
Clyde W. Dent, PhD
Arch Pediatr Adolesc Med. 2001;155:1043-1050.
ABSTRACT
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Objective To determine the cost-effectiveness of a school-based tobacco-use prevention
program.
Design Using data from the previously reported 2-year efficacy study of the
Project Toward No Tobacco Use (TNT), we conducted a decision analysis to determine
the cost-effectiveness of TNT. The benefits measured were life years (LYs)
saved, quality-adjusted life years (QALYs) saved, and medical care costs saved,
discounted at 3%. The costs measured were program costs. We quantified TNT's
cost-effectiveness as cost per LY saved and cost per QALY saved.
Intervention A 10-lesson curriculum designed to counteract social influences and
misconceptions that lead to tobacco use was delivered by trained health educators
to a cohort of 1234 seventh-grade students in 8 junior high schools. A 2-lesson
booster session was delivered to the eighth-grade students in the second year.
The efficacy evaluation was based on 770 ninth-grade students who participated
in the program in the seventh and eighth grades and in both the baseline and
the 2-year follow-up survey.
Results Under base case assumptions, at an intervention cost of $16 403,
TNT prevented an estimated 34.9 students from becoming established smokers.
As a result, we could expect a saving of $13 316 per LY saved and a saving
of $8482 per QALY saved. Results showed TNT to be cost saving over a reasonable
range of model parameter estimates.
Conclusions The TNT is highly cost-effective compared with other widely accepted
prevention interventions. School-based prevention programs of this type warrant
careful consideration by policy makers and program planners.
INTRODUCTION
TOBACCO USE is widely acknowledged to be the leading cause of preventable
death in the United States.1 Approximately
434 000 Americans die each year as a result of smoking; these deaths
have been associated with more than 5 million years of potential life lost.2 Direct medical costs attributable to smoking total
at least $50 billion per year.3 Because most
daily smokers (82%) begin smoking before age 18 years and more than 3000 young
people become regular smokers each day,4 school
programs designed to prevent tobacco use have been identified as one of the
most effective strategies available to reduce tobacco use in the United States.5, 6 In the past decade, numerous school-based
primary prevention programs to reduce tobacco use among youth have been developed
and implemented across the United States. These programs can be an effective
means of preventing tobacco use among youth, especially those programs that
focus on counteracting the social influences that may facilitate adolescent
tobacco use.7, 8, 9, 10, 11
While the behavior-change effectiveness of selected school-based tobacco-use
prevention programs has been established,12, 13, 14
no studies, to our knowledge, have examined their cost-effectiveness. Because
resources to fund school-based tobacco-use prevention programs are limited,
determining that a program is effective may not be adequate to justify its
implementation. Issues of practical concern to policy makers and program planners
are cost (ie, whether they can afford a particular prevention program) and
cost-effectiveness (ie, whether the effects of a program justify the cost
of its implementation).
The objective of this study is to use economic evaluation techniques
to determine the cost-effectiveness of the Project Toward No Tobacco Use (TNT),
a school-based education program designed to prevent tobacco use among junior
and se nior high school students. The TNT is a comprehensive social skills
program comprising activities that counteract normative and informational
social influences to use tobacco and misconceptions about the physical consequences
of tobacco use. The program teaches refusal skills, awareness of social misperceptions
about tobacco use, and misconceptions about physical consequences.
An efficacy evaluation of TNT11 was implemented
during the 1989-1990 and 1990-1991 school years. Although this efficacy study
seems somewhat dated, we chose to use TNT in our cost-effectiveness study
for 3 main reasons: (1) economic evaluations of behavioral interventions usually
are conducted on the basis of results from efficacy or effectiveness studies,
and most of the rigorously evaluated school-based tobacco-use prevention programs,
including TNT, were implemented during the late 1980s and early 1990s12; (2) the Centers for Disease Control and Prevention,
Atlanta, Ga, has identified TNT as a Program That Works on the basis of credible
evidence of its efficacy in reducing tobacco use among youth; and (3) TNT
has been chosen as a model program by the Center for Substance Abuse Prevention.
The efficacy evaluation was designed to test the effectiveness of 3
separate social influence curricula (a physical consequences curriculum, an
informational social influence curriculum, and a normative social influence
curriculum) and a fourth combined-strategy curriculum. Forty-eight junior
high schools in southern California were assigned randomly to 1 of the 4 curricula
or to a "usual care" curriculum. (A detailed description of the efficacy study
design, including the randomization process, is provided elsewhere.15)
The 10-lesson curricula were first delivered to a cohort of seventh-grade
students in 1989, and a 2-lesson booster session was given to the eighth-grade
cohort the following year. The baseline data were collected from 6716 seventh-grade
students; 50% of the students were boys; 60%, white; 27%, Hispanic; 7%, black;
and 6%, Asian or "other." Two-year follow-up data were collected from 7219
ninth-grade students, 65% of whom reported attending a junior high school
at which TNT curricula were offered 2 years earlier. The outcome variables
tested were changes in trial and weekly cigarette and smokeless tobacco use
2 years after the intervention.
Results of the 2-year follow-up study showed that each single-strategy
curriculum was effective only on trial tobacco use but that the combined-strategy
curriculum was effective on both trial and weekly tobacco use. On the basis
of these findings, the combined intervention program has since been disseminated.
Thus, we used the combined intervention for our economic analyses. The efficacy
study showed that TNT was effective in preventing both cigarette use and smokeless
tobacco use. We focused our study on the prevention of cigarette smoking because
there are more detailed descriptions of mortality directly associated with
cigarette smoking than with smokeless tobacco use.
Of a cohort of 1234 seventh-grade students who participated in the combined
intervention, 770 participated in the 2-year follow-up survey as ninth-graders.
Of 1956 students recruited as a control group, 1565 were surveyed at the 2-year
follow-up. During the 2 years, trial cigarette use among students participating
in the combined intervention increased from 37% to 53%, and weekly use increased
from 6% to 10%. Among students in the control group, trial cigarette use increased
from 35% to 58%, and weekly cigarette use increased from 4% to 13%. There
was no difference in effectiveness by gender.
SUBJECTS AND METHODS
Because program selection decisions often are made in the interest of
society as a whole, we conducted this study from a societal perspective, which
considers everyone affected by the intervention and counts the most significant
health outcomes and costs that are attributable to the intervention. We used
standard methods of cost-effectiveness analysis and measured benefits in terms
of life years (LYs) saved, quality-adjusted life years (QALYs) saved, and
lifetime medical costs saved, discounted at a 3% annual rate as recommended
by the Panel on Cost-effectiveness in Health and Medicine.16
Program costs incurred during the 2-year implementation were included as intervention
costs. All costs were in 1990 dollars to correspond with the timing of the
intervention. The cost-effectiveness of TNT was compared with the control
scenario and was assessed in terms of cost per LY saved and cost per QALY
saved.
Although nonsmokers generally have longer life expectancies than smokers,
no study to our knowledge has examined the impact of primary smoking prevention
on life expectancy. To overcome the gaps in existing research, we used an
intermediate outcome measure—number of established smokers prevented.
We first translated the relative reduction in trial cigarette use and weekly
cigarette use into the number of established smokers prevented and then translated
the number of established smokers prevented into LYs saved and QALYs saved.
To our knowledge, our study is the first that used such translations.
The base-case analysis was conducted in 5 steps: (1) a retrospective
estimation of the intervention cost, (2) an estimation of the number of students
prevented from becoming established smokers by age 26 years, (3) an estimation
of the number of LYs saved and QALYs saved by the intervention, (4) an estimation
of the lifetime medical care costs saved by the intervention, and (5) a calculation
of the cost-effectiveness of the intervention. We conducted multivariate and
univariate sensitivity analyses to determine the robustness of the base-case
analysis and identify the parameters that had the most influence on the results.
INTERVENTION COST
We estimated the direct costs of program delivery (Table 1) incurred in the combined intervention, including the cost
of training of health educators, the cost of teaching students, and the cost
of materials used. In the trial study, 8 schools were assigned to each of
the 4 curricula. Nine health educators received 3 weeks of training (120 hours)
at an hourly rate of $10 before delivering the curriculum. A master trainer
charged $500 per day for conducting the training, or $56 per health educator
trained. On the basis of the total number of students who received 1 of the
4 interventions (5263) and the number of students who received the combined
intervention (1234), we estimated that 2 health educators would actually be
needed for the combined intervention only. During the first year of implementation,
the 10-lesson combined curriculum was delivered to 45 classes of seventh-grade
students with an average of 5.6 classes per school. Each health educator taught
in 4 schools during an 8-week period, 2 weeks for each school. During the
second year, 2-lesson booster sessions were delivered to the eighth-grade
students at each school. The health educators worked 8 hours a day (5-6 hours
of teaching and 2-3 hours of preparation) at an hourly rate of $10. Each health
educator received a copy of the teacher manual, which cost $45, and each student
received a copy of a student guide book, which cost $3.69.
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Table 1. Intervention Costs*
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ESTABLISHED SMOKERS PREVENTED
As shown in Figure 1, we developed
a smoking progression model to estimate the number of students (of the 770
total participants) who would become established smokers by age 26 years in
the intervention scenario and in the control scenario. At the 2-year follow-up,
the 770 students were divided into nonsmokers (ever smoked <1 cigarette),
experimenters (ever smoked  1 but <100 cigarettes), and established
smokers (ever smoked 100 cigarettes).
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Smoking progression model. Parameters in parentheses indicate control
scenario. All ages are given in years.
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Because the students were young adolescents (average age, 14 years),
we considered the likelihood that some current nonsmokers or experimenters
would become established smokers in the future by using the natural history
information reported by Pierce et al17 on smoking
behavior in a national sample of 4500 adolescents aged 12 to 18 years who
at baseline reported never having taken a puff from a cigarette. Pierce et
al17 reported the probabilities of smoking
progression over a 4-year time period by smoking behavior (experimentation
with smoking and established smoking) and by baseline age. To use their estimates
in our study, we modeled the smoking progression of nonsmokers and experimenters
over three 4-year age periods: ages 14 to 18, 18 to 22, and 22 to 26 years.
We assumed that initiation of established smoking ends after age 26 years,
since most established smokers started smoking before age 18 years.
Using this model, we first calculated the probability of a 14-year-old
experimenter becoming an established smoker by age 26 years (Xe)
and the probability of a 14-year-old nonsmoker becoming an established smoker
by age 26 years (Xn). We then estimated the total number of established
smokers to be expected in the intervention scenario (Yi), the total
number of established smokers to be expected in the control scenario (Yc), and the total number of students who will be prevented from becoming
established smokers by the intervention (Y):
(1) Xe = C1 + (1 - C1)C2 + (1 - C1) (1 - C2)C3
(2) Xn = B1 + (A1 - B1)C2 + (A1 - B1) (1 - C2)C3 + (1 - A1)[B2 + (A2 - B2)C3 + (1 - A2)B3]
(3) Yi = N[Qi + (Pi - Qi)Xe + (1 - Pi)Xn]
(4) Yc = N[Qc + 2% + (Pc -
Qc)Xe + (1 - Pc - 2%)Xn]
(5) Y = Yc - Yi
where C1, C2, and C3 are the probabilities
of an experimenter becoming an established smoker during each of the three
4-year periods. A1 and A2 are the probabilities of a
nonsmoker initiating smoking during each of the first two 4-year periods.
B1, B2, and B3 are the probabilities of a
nonsmoker becoming an established smoker during each of the three 4-year periods.
P is the percentage of students who had initiated smoking by the 2-year follow-up;
Pi, the percentage in the intervention scenario; Pc,
the percentage in the control scenario; and Pc + 2%, the adjusted
percentage in the control scenario (2% representing the adjustment for the
baseline difference between the intervention and control group). Q is the
percentage of students who had become established smokers by the 2-year follow-up;
Qi, the percentage in the intervention scenario; Qc,
the percentage in the control scenario; and Qc + 2%, the adjusted
percentage in the control scenario (2% representing the adjustment for the
baseline difference between the intervention and control group). The values
and sources of each of these parameters are listed in Table 2.
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Table 2. Data Used to Estimate the Number of Established Smokers Prevented
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Because no published study is available on the probability of experimenters
becoming established smokers, we made assumptions for each 4-year period.
Because experimenters already had shown interest in smoking, we assumed that
the probability of an experimenter becoming an established smoker during each
age interval was 2 times the probability of a nonsmoker becoming an established
smoker.
LYs AND QALYs SAVED
To translate the number of established smokers prevented into the number
of LYs saved, we used estimates of life expectancies derived by Rogers and
Powell-Griner18 based on data from the National
Health Interview Survey and the National Mortality Followback Survey. These
estimates were reported by age and sex for those who had never smoked ("never
smokers"), former smokers, and current smokers in the United States in 1986.
Never smokers included nonsmokers and experimenters, and current smokers were
further divided into light smokers (smoked <25 cigarettes per day) and
heavy smokers (smoked 25 cigarettes per day). On the basis of their life
table values for smoking status for the 25- to 29-year-old age group, we estimated
the distribution of each type of smoker. As given in Table 3, of all smokers in the 25- to 29-year-old age group, 31.7%
were former smokers, 52.3% were light smokers, and 16% were heavy smokers.
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Table 3. Data Used to Estimate LYs* Saved (Discounted at 3%)
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We also estimated the LYs saved by preventing a never smoker from becoming
a smoker by comparing the life expectancy of each type of smoker with that
of a never smoker. The life expectancy of a never smoker is 2 years longer
than that of a former smoker, 3.5 years longer than that of a light smoker,
and 14.2 years longer than that of a heavy smoker. When we discounted those
LYs at an annual rate of 3%, we estimated an average gain of 0.26 discounted
LYs for a former smoker prevented, 0.47 discounted LYs for a light smoker
prevented, and 2.13 discounted LYs for a heavy smoker prevented. Thus, for
each established smoker prevented, the weighted average of discounted LYs
saved is 0.67 (31.7% x 0.26 + 52.3% x 0.47 + 16% x 2.13).
We calculated the total number of discounted LYs saved by the intervention
by multiplying the number of discounted LYs saved per established smoker prevented
by the number of established smokers prevented.
To further convert discounted LYs saved into discounted QALYs saved,
we used published estimates from the study by Cromwell et al.19
In their study, 1.31 LYs saved per quitter was estimated as 2.34 QALYs saved
for men aged 25 to 29 years, and 1.43 LYs saved was estimated as 1.94 QALYs
saved for women aged 25 to 29 years. Using these estimates, we calculated
that a weighted average of 1.57 QALYs saved was equivalent to 1 LY saved.
MEDICAL COSTS SAVED BY THE INTERVENTION
To estimate the medical costs saved by the intervention, we needed to
know the lifetime medical expenditure associated with becoming a smoker vs
not becoming a smoker. Hodgson's study20 of
the lifetime cost of smoking-related illness had the most suitable estimates
for this study. Hodgson used data on the use and costs of medical care and
on mortality during each age interval in cross sections of the US population
to generate profiles of lifetime health care costs beginning at age 17 years.
The profiles, estimated for men and women by age and amount smoked, included
the costs of inpatient hospital care, physician services, and nursing home
care. Over a lifetime an average male smoker spent $8638 more than a never
smoker for medical care and an average female smoker spent $10 119 more
(1990 US $ discounted at 3%).
Based on Hodgson's estimates, the average expected lifetime medical
care costs associated with becoming a smoker were $9379 more than those of
not becoming a smoker. We calculated the total medical costs averted by the
intervention as the number of established smokers prevented multiplied by
the expected lifetime excess medical care costs per smoker.
COST-EFFECTIVENESS OF THE INTERVENTION
We calculated the cost-effectiveness ratio as the net cost per LY saved
and the net cost per QALY saved. We calculated the net cost by subtracting
medical care costs from intervention costs. Most published cost-effectiveness
studies of smoking cessation programs for adults do not include medical care
cost savings resulting from smoking cessation. Thus, to make our results comparable
with these published results, we recalculated the cost-effectiveness of TNT
by excluding the medical care costs savings resulting from the intervention.
SENSITIVITY ANALYSES
Because the model parameters depended largely on estimates from single
studies, we examined the cost-effectiveness ratios for both high and low values
of each key parameter in the analysis. Using multivariate and univariate sensitivity
analyses to test the robustness of our base-case results and identify parameters
that had the most influence on results, we examined 12 key parameters: the
hourly pay per health educator, the medical care costs, and the 10 parameters
(Pc, Qc, A1, A2, B1,
B2, B3, C1, C2, C3)
that were used to estimate the number of established smokers prevented as
presented in Table 2.
We conducted multivariate sensitivity analyses through 2 steps. First,
we performed a computer simulation using SAS (SAS Institute, Cary, NC) to
estimate the most and the fewest number of established smokers prevented by
varying the values of each of the 10 key parameters over a reasonable range.
Parameter values for each simulation trial were selected randomly from the
2 bound values of each parameter. As given in Table 2, for 6 of those parameters (Pc, Qc,
A1, A2, B1, B2), we assumed that
the estimates were normally distributed and used a 95% confidence interval
to determine a plausible range for variation. Because no data were available
for the other 4 parameters (B3, C1, C2, C3), we based the lower- and upper-bound estimates on assumptions.
Then we estimated the best- and worse-case cost-effectiveness scenarios
by varying the estimates of 3 parameters: the number of established smokers
prevented, intervention costs, and medical care costs. Because the hourly
pay per health educator in a real-world scenario could be very different from
the actual trial scenario, we altered the intervention costs from $16 403
to $36 563 by increasing the hourly pay per health educator from $10
to $30. Although Hodgson's study20 assessed
the medical cost impact of becoming a smoker vs not becoming a smoker, it
did not control for other differences between smokers and never smokers besides
smoking that affect medical costs. According to a research reported by Manning
et al,21 when other lifestyle choices are controlled,
excess lifetime medical costs of smokers compared with nonsmoking smokers
(people who are like smokers in age, sex, education, drinking habits, and
several other ways, except that they have never smoked) is 87% of the excess
lifetime costs of smokers compared with never smokers. For sensitivity analyses,
we used Hodgson's estimate of $9379 as our upper-bound estimate and used an
estimate of $8160 (87% of $9379) as our lower-bound estimate. To test the
sensitivity of the results to the uncertainty in individual parameters, we
conducted univariate sensitivity analysis on 1 parameter at a time.
RESULTS
Table 4 displays the results
from both the base-case analysis and the multivariate sensitivity analyses.
Under base-case assumptions, at an intervention cost of $16 403 ($13.29
per student), we estimated that the combined intervention would prevent 34.9
students from becoming established smokers. As a result, society could expect
to save $327 140 in medical care costs and a total of 23.3 discounted
LYs and a total of 36.6 discounted QALYs. This translated to a cost-saving
of $13 316 per LY saved and a cost-saving of $8482 per QALY saved. When
we excluded the medical care costs from the analyses, we estimated that the
intervention would cost $703 per LY saved and $448 per QALY saved.
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Table 4. Results From Base-Case and Multivariate Sensitivity Analyses*
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On the basis of 1024 simulation trials in the first step of the multivariate
sensitivity analyses, we estimated that the number of established smokers
prevented would range from 19.7 to 51.0. From the second step of the multivariate
sensitivity analyses, we estimated that the cost-savings would range from
$9427 to $13 539 per LY saved and from $6004 to $8623 per QALY saved.
When medical care costs were excluded from the cost-effectiveness calculation,
the estimated cost-effectiveness of the intervention ranged from $481 to $2770
per LY saved and $306 to$1764 per QALY saved. These results demonstrated that
the cost-effectiveness ratios were robust over a reasonable range of 12 parameter
estimates. The intervention can thus be expected to yield net benefits to
society under all scenarios considered.
Table 5 presents the results
of the univariate analysis for each of the 12 key parameters. The estimate
of the cost-effectiveness ratios was relatively insensitive to the uncertainty
in individual parameters. The one exception was the effect of the estimate
of the percentage of weekly cigarette users in the control group. For that
parameter, the cost-effectiveness ratios varied from a cost-savings of $18 729
to $10 326 per LY saved. Such results indicate that the prevalence rate
of established smoking has the most influence on the cost-effectiveness results,
which warrants careful examination by researchers in future evaluation studies.
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Table 5. Univariate Sensitivity Analysis
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COMMENT
This study had some clear limitations. First, the study was retrospective,
so costs were estimated rather than prospectively measured. Second, the number
of established smokers prevented was modeled rather than directly measured.
Third, only one source of data was available for the probabilities of smoking
progression by nonsmokers; therefore, we had to use 95% confidence interval
estimates for sensitivity analyses. Fourth, no data were available in the
literature to describe the probabilities of experimenters becoming established
smokers, so we had to make assumptions for each age interval. Fifth, because
there are no data to suggest that never smokers in the intervention condition
are either less or more likely to initiate smoking than never smokers in the
control condition, we used an average transition probability for the population
as a whole for the behavior of those who have been in the trial. Sixth, we
did not consider the continued effectiveness of TNT past the 2-year intervention,
nor the effectiveness of TNT on reducing smokeless tobacco use. However, exclusion
of those effectiveness measures should yield conservative estimates of the
cost-effectiveness of TNT. Seventh, we did not fully account for all the costs
of smoking to society, such as passive smoking, smoking-related fires, and
maternal smoking on the health, birth outcomes, and long-term growth of infants.
However, inclusion of the other costs in our study could only improve the
cost-effectiveness of the TNT program and will not affect the general conclusions
of this study.
Even with these limitations, we have been cautious in our approach and
have carefully examined the robustness of our results. The sensitivity analyses
indicated that the results are generally robust with respect to most of the
key sources of uncertainty in the analysis. It is justifiable to conclude
that TNT is both cost-effective and cost saving under all scenarios considered.
The cost-effectiveness of this primary prevention intervention are even
more impressive when compared with results of studies of some widely accepted
secondary prevention interventions such as breast cancer screening or cervical
cancer screening. For example, routine screening for cervical cancer with
Papanicolaou testing for all women aged 15 to 74 years was estimated to cost
$22 000 (in 1996 dollars) for every year of life saved, and annual breast
cancer screening for women age 50 to 69 years was estimated to cost $46 000
(in 1996 dollars) for every year of life saved.22
When compared with smoking cessation programs for adults, the cost-effectiveness
of TNT is still attractive. The cost-effectiveness ratios of $481 to $2770
per LY saved (excluding medical costs) are generally consistent with those
of most smoking cessation programs and, in some cases, more cost-effective.
For example, the cost-effectiveness ratio of physicians' smoking cessation
counseling was found to range from $705 to $2058 (in 1984 dollars, or $1074-$3136
in 1990 dollars) per LY saved23; the cost-effectiveness
ratio of nicotine gum as an adjunct to physician's advice was found to range
from $4113 to $9473 (in 1984 dollars, or $6268-$14 436 in 1990 dollars)
per LY saved24; and the cost-effectiveness
ratio of the nicotine patch with brief physician counseling was found to range
from $965 to $2360 (in 1995 dollars, or $712-$1742 in 1990 dollars) per LY
saved.25
The results of this study suggest that school-based tobacco-use prevention
programs can be delivered at a reasonable cost and can be highly cost-effective
and cost-saving. Primary prevention programs of this type warrant careful
consideration by policy makers and program planners when resource allocation
and curriculum decisions are made. The findings of this study also suggest
that a school-based primary prevention intervention can be as cost-effective
as secondary prevention interventions, such as tobacco-use cessation programs
for adults. To reduce overall tobacco use, we recommend increasing investment
in primary prevention programs for youth. With increased funding for tobacco-use
prevention as a result of state settlements with tobacco companies, policy
makers should expand school-based primary prevention programs as part of comprehensive
tobacco control programs to significantly reduce the adverse health outcomes
of smoking in our society.
Over the past decades, economic evaluation research has focused on smoking
cessation programs for adult smokers. As more school-based smoking prevention
programs demonstrate effectiveness in preventing tobacco use, it will be increasingly
important to study their cost-effectiveness so that policy makers and school
health administrators can look beyond program effectiveness in making decisions.
To improve future analyses and to help these leaders make more informed choices
about the prevention of tobacco use among adolescents, we recommend additional
research into the stages of smoking establishment from adolescence to adulthood,
the medical costs of treating smoking-related diseases, and the life expectancy
of smokers and nonsmokers. Researchers should routinely include program cost
data in their program evaluations so that more economic evaluations of school-based
tobacco-use prevention programs can be conducted.
AUTHOR INFORMATION
Accepted for publication April 26, 2001.
Presented at the American Public Health Association 128th Annual Meeting,
Boston, Mass, November 15, 2000, and the 74th National School Health Conference
of the American School Health Association, New Orleans, La, October 27, 2000.
We thank Jeffery Fellows, PhD, for his review and insightful comments
on the manuscript.
What This Study Adds
In the past decade, numerous school-based primary prevention programs
to reduce tobacco use among youth have been developed and implemented across
the United States. Research studies have shown that school-based social influences
curricula are effective in preventing tobacco use among youth. While the behavior-change
effectiveness of selected school-based tobacco-use prevention programs has
been established, no studies have examined their cost-effectiveness.
School-based tobacco-use prevention programs can be delivered at a reasonable
cost and can be highly cost-effective and cost saving. Primary prevention
programs of this type warrant careful consideration by policy makers and program
planners when resource allocation and curriculum decisions are made. With
increased funding for tobacco-use prevention as a result of state settlements
with tobacco companies, policy makers should expand school-based primary prevention
programs as part of comprehensive tobacco control programs to considerably
reduce the adverse health outcomes of smoking in our society.
From the Surveillance and Evaluation Research Branch, Division of Adolescent
and School Health, Centers for Disease Control and Prevention, Atlanta, Ga
(Mss Wang and Crossett and Dr Lowry); and the Institute for Health Promotion
and Disease Prevention Research, University of Southern California, Los Angeles
(Drs Sussman and Dent).
Corresponding author and reprints: Li Yan Wang, Surveillance and
Evaluation Research Branch, DASH, NCCDPHP, 4770 Buford Hwy, MS K-33, Chamblee,
GA 30341 (e-mail: lgw0{at}cdc.gov).
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