Study explores most cost-effective smoking cessation methods in lung cancer screening

A streamlined combination of intensive counseling and short-term nicotine replacement therapy appears to offer health systems the best value for helping patients quit smoking during lung cancer screening, according to an economic evaluation published last month in JAMA Network Openby researchers at the Mongan Institute Health Policy Research Center at Massachusetts General Hospital in Boston. Among eight smoking cessation strategies tested, eight sessions of counseling delivered by telehealth combined with two weeks of nicotine replacement therapy emerged as the most cost-effective approach.

Smoking cessation is a central component of lung cancer screening programs, given the strong link between tobacco use and lung cancer outcomes. Tobacco smoking accounts for approximately 80% of lung cancer deaths, and current US Preventive Services Task Force recommendations advise that people eligible for lung cancer screening should also be offered smoking cessation services. Although multiple cessation approaches have demonstrated effectiveness, less is known about how their costs compare when implemented within screening programs.

To address that gap, a team of investigators led by Douglas E. Levy, Ph.D., associate professor at Harvard Medical School, conducted a preplanned economic evaluation of the Screen Aiding Screening Support In Stopping Tobacco (ASSIST) trial. The trial was conducted at 11 lung cancer screening sites within a single Massachusetts health system and enrolled patients who smoked and were scheduled for lung cancer screening between April 2019 and July 2023. The analysis included 642 participants with an average age of 64 years.

The Screen ASSIST trial tested eight combinations of smoking cessation interventions. Participants were randomized to receive either four or eight behavioral counseling sessions, two or eight weeks of free nicotine replacement therapy patches, and either screening or no screening for adverse social determinants of health with referral to community services when needed. The primary effectiveness outcome was self-reported seven-day smoking abstinence at six months.

From a health-system perspective, researchers prospectively assessed start-up and operating costs and calculated incremental cost per quit relative to usual care. Total start-up costs reached $131,371, largely driven by electronic health record programming needed to identify eligible patients. Operating costs across intervention conditions ranged from $196,272 to $274,865.

The most cost-effective strategy was eight counseling sessions combined with two weeks of nicotine replacement therapy and no screening for social determinants of health. This approach yielded an incremental cost per quit of $3,050, with a 95% confidence interval of $1,286 to $4,815. Sensitivity analyses suggested that per-patient costs and incremental cost per quit would be lower in health systems serving larger patient populations.

“Guidelines recommend that folks eligible for lung cancer screening (LCS), who are still using tobacco, be offered smoking cessation services,” Levy says. “Healthcare systems working to adhere to these guidelines want to know not only which strategies work to help people quit, but also which strategies are affordable to operate.”

Levy adds that “a program of intensive counseling (8 sessions over 12 weeks) and a starter course of nicotine replacement therapy (2 weeks' worth of patches) was both the most effective and the most cost-effective strategy to help LCS patients quit smoking.”

According to Levy, the single most expensive line item was neither the counseling nor nicotine replacement therapy, but setting up the computer system needed to identify eligible patients. That cost that would be lower for health systems that already have computerized ways of spotting candidates for smoking cessation already in place.

“Costs will also be lower for systems with larger volumes of LCS patients using tobacco, as that spreads the fixed costs over a larger group of people,” he adds.

The authors emphasize that local context will shape real-world costs, particularly electronic health record capabilities, payment models, wage variation and screening volume. Still, the findings may help healthcare systems make more informed decisions as they work to integrate effective and sustainable smoking cessation services into lung cancer screening workflows.