437

Chapter 5

The Benefits of Smoking Cessation on Overall Morbidity, 

Mortality, and Economic Costs

Introduction 439

Benefits of Smoking Cessation on Overall Morbidity 439

Conclusions from Previous Surgeon General’s Reports 439

Description of the Literature Review 440

Assessment of Morbidity 440

Assessment of Smoking Status 440

Epidemiologic Evidence 457

Cross-Sectional Studies 457

Longitudinal Studies 458

Synthesis of the Evidence 460

Summary of the Evidence 460

Benefits of Smoking Cessation on All-Cause Mortality 461

Conclusions from Previous Surgeon General’s Reports 461

Summary of the Evidence 464

Benefits of Smoking Cessation on Economic Costs 465

Economic Costs of Smoking 465

Economics of Smoking Cessation 466

Principles of Cost-Benefit and Cost-Effectiveness Analysis 467

Cost-Effectiveness of Clinical Smoking Cessation Interventions 467

Cost-Effectiveness of Nonclinical Smoking Cessation Interventions 482

Cost-Effectiveness of Tobacco Price Increases Through Taxation 482

Synthesis of the Evidence 482

Summary of the Evidence 485

Conclusions 485

References 486

The Benefits of Smoking Cessation on Overall Morbidity, Mortality, and Economic Costs 439

Smoking Cessation

Introduction

Cigarette smoking causes multiple diseases and 

reduces the general level of health of smokers (U.S. 

Department of Health and Human Services [USDHHS] 

2004, 2014). These health consequences have been well 

documented in previous Surgeon General’s reports. The 

1964 report first summarized results on smoking and allcause mortality, finding that smoking causes a 70% increase 

in risk of adverse health consequences (U.S. Department 

of Health, Education, and Welfare [USDHEW] 1964). The 

2004 report found smoking generally diminishes health 

(USDHHS 2004). General measures of health can be informative because they provide an integrative indicator of the 

health burden placed on smokers and on society overall. 

In addition to the direct human costs that smoking places 

on persons and society, one general measure with acknowledged implications for public health policy and practice is 

the economic cost of smoking.

This chapter considers broad indicators of burden 

in relation to smoking cessation, including morbidity, 

mortality, and economic costs. Initially, it considers how 

general indicators of health can change after smoking cessation. This type of information is critical to informing 

smokers about the potential benefits of cessation and serves 

as a strong rationale to provide interventions that can 

help increase the success of quitting smoking. Such programs may be offered through healthcare organizations, 

communities, states, and other organizations. Smoking is 

known to generate healthcare and other economic costs 

and to affect the economics of the households of smokers 

(USDHHS 2014). Previous Surgeon General’s reports on 

tobacco have periodically reviewed the economic costs of 

smoking, as tracked by the Centers for Disease Control 

and Prevention’s (CDC’s) Smoking-Attributable Mortality, 

Morbidity, and Economic Costs (SAMMEC) model. This 

chapter expands on this work by focusing on the most 

recently available scientific literature on the economic benefits of smoking cessation, while also complementing the 

kinds of cost estimates previously provided by SAMMEC.

Benefits of Smoking Cessation on Overall Morbidity

Chapter 4 of this report (The Health Benefits of 

Smoking Cessation) describes the associations between 

smoking cessation and changes in risk for specific disease outcomes. It also addresses how cessation affects the 

natural history of various disease outcomes, such as by 

slowing the progression of underlying pathophysiological 

processes. In addition to the beneficial impacts on specific disease outcomes, previous reviews of smoking cessation and morbidity (Goldenberg et al. 2014) have concluded that cessation is associated with improvement in 

health-related quality of life (HRQoL), a broad construct 

defined by Healthy People 2020 as “a multi-dimensional 

concept that includes domains related to physical, mental, 

emotional, and social functioning” (Office of Disease 

Prevention and Health Promotion 2018). In a complementary conclusion, after evaluating a broad range of general 

evidence, the 2004 Surgeon General’s report concluded 

that active smoking is causally associated with diminished 

health status (USDHHS 2004).

This chapter addresses the evidence on smoking 

cessation and its relationship to more general measures of health outcomes, particularly whether cessation 

improves general QoL compared with continued smoking. 

This review aligns with and complements the approach 

used in previous Surgeon General’s reports on smoking, 

including the 2014 Surgeon General’s report (USDHHS 

2014). However, to limit the scope of this review, some of 

the many correlates of well-being (e.g., absenteeism from 

work) are not specifically considered.

Conclusions from Previous Surgeon 

General’s Reports

Previous Surgeon General’s reports (USDHHS 1990, 

2004) have comprehensively covered the relationship 

between smoking and general morbidity. The 1990 Surgeon 

General’s report on the health benefits of smoking cessation synthesized scientific evidence about cessation and 

its effects on general morbidity, concluding that “former 

smokers have better health status than current smokers 

as measured in a variety of ways, including days of illness, 

number of health complaints, and self-reported health 

status” (USDHHS 1990, p. 9). However, that report also 

found that the reviewed studies were “extremely heterogeneous, with some methodologic shortcomings” (USDHHS 

1990, p. 89) and that the “variety of measures used makes 

direct comparison across studies problematic” (USDHHS 
A Report of the Surgeon General

440 Chapter 5

1990, p. 87). The 2004 Surgeon General’s report on the 

health consequences of active smoking subsequently 

reviewed studies that included various indicators of general health, concluding that “the evidence is sufficient to 

infer a causal relationship between smoking and diminished health status that may be manifest as increased 

absenteeism from work and increased use of medical care 

services” (USDHHS 2004, p. 676). In addition, a major 

conclusion of the 2004 report was that “quitting smoking 

has immediate as well as long-term benefits, reducing 

risks for diseases caused by smoking and improving health 

in general” (USDHHS 2004, p. 25). The present chapter 

updates these findings on the basis of more recent studies 

of smoking cessation and indicators of general morbidity.

Description of the Literature Review

Scientific literature from 1990 to 2017 was systematically reviewed, and reference lists from the identified 

articles were searched for additional studies. Search terms 

included “smoking cessation,” “epidemiology,” “morbidity,” “health status,” and “quality of life.” Studies were 

included if they measured the benefit of smoking cessation for general morbidity in former cigarette smokers; 

thus, the appropriate comparison group was continuing 

cigarette smokers but not never smokers. Accordingly, 

only studies that specifically and directly compared outcomes between former cigarette smokers (defined in 

multiple ways) and current cigarette smokers were considered. Studies that included former cigarette smokers 

but used only never smokers as the reference group were 

not included because such studies were not informative 

for the purpose of this chapter. However, when informative comparisons were made in eligible studies that met 

the criterion of comparisons with current smokers, some 

findings for never smokers were included.

Following the systematic review of literature, 

24  studies published from 1995 to 2016 were identified 

that assessed smoking cessation and general morbidity, 

including 7 cross-sectional studies (Table 5.1) (Tillmann 

and Silcock 1997; Olufade et al. 1999; Mulder et al. 2001; 

Bolliger et  al. 2002; Mody and Smith 2006; Heikkinen 

et al. 2008; McClave et al. 2009) and 16 prospective cohort 

studies (Tables 5.2–5.4) (Stewart et al. 1995; Taira et al. 

2000; Bolliger et  al. 2002; Zillich et  al. 2002; Erickson 

et al. 2004; Mitra et al. 2004; Croghan et al. 2005; Wiggers 

et  al. 2006; Jensen et  al. 2007; Rungruanghiranya et  al. 

2008; Gutiérrez-Bedmar et al. 2009; Balduyck et al. 2011; 

Papadopoulos et  al. 2011; Hays et  al. 2012; Piper et  al. 

2012; Tian et al. 2016).

Assessment of Morbidity

The general measures of morbidity used in the 

24 identified studies varied but cover three main categories: general, smoking specific, or disease specific:

1. General. Many studies used general measures of

HRQoL, most frequently the Short Form (SF)-36

(SF-36) and SF-12 surveys, both the Medical

Outcomes Study (Ware Jr and Sherbourne 1992)

and RAND versions (Hays and Morales 2001). One

study (Mitra et al. 2004) adapted the SF-36 for use

in a population with mobility impairments. The

other generic measures of HRQoL included the 15-D

(dimensional) (Sintonen 1995), the EuroQoL (The

EuroQol Group 1990), the QoL Inventory (Frisch

et al. 1992), the World Health Organization’s QOLBREF (Skevington et al. 2004), CDC’s HRQOL-4 and

its Healthy Days Symptoms Module (Moriarty et al.

2003), and the Functional Status Questionnaire

(Jette et al. 1986). The studies identified in the literature review also assessed dissatisfaction with life

and general health status.

2. Smoking specific. One study (Olufade et al. 1999)

used the Smoking Cessation Quality of Life (SCQoL)

questionnaire.

3. Disease specific. Some studies used disease-specific

measures of HRQoL. These measures assess the

impact of specific diseases on relevant components

of QoL. The European Organisation for Research and 

Treatment of Cancer (EORTC) QoL Questionnaire

QLQ-C30 (Aaronson et al. 1993) was used, along with 

the LC13 module for lung cancer (Bergman et  al.

1994) and the H&N35 module for head and neck

cancer (Bjordal et  al. 1994). Other disease-specific

instruments included the Aquarel questionnaire for

patients with pacemakers (Stofmeel et al. 2001), the

Clinical COPD Questionnaire (van der Molen et al.

2003), and the VascuQoL questionnaire for patients

with peripheral arterial disease (Morgan et al. 2001).

Assessment of Smoking Status

Most of the 24 identified studies assessed cigarette 

smoking status by self-report. Self-reported smoking 

status continues to be sufficiently valid and reliable for 

studying the general population but may be less accurate 

for assessing smoking in high-risk or medical patients 

(Velicer et al. 1992; USDHHS 2004, 2014).
Study Design/population Smoking status Health status measure Outcomes/findings Comments

Tillmann and 

Silcock (1997)

•

•

•

•

•

Cross-sectional 

study

Current smokers 

and ex-smokers 

randomly selected 

from records of nine 

general practices

n = 3,000

1995

Scotland

•

•

Current smokers 

(n = 1,500)

Ex-smokers of 

5 years or more 

(n = 1,500)

•

•

SF-36

EuroQoL tariff 

scores

•

•

HRQoL, as measured by SF-36 and EuroQoL 

tariff scores, was significantly higher for 

ex-smokers than for current smokers. 

Mean difference by measure and QoL 

dimension: 

–

–

–

–

–

–

–

–

–

EuroQoL tariff: 0.03 (95% CI, 0.011–0.058), 

p = 0.004 

Physical functioning: 3.93 (95% CI, 1.267– 

6.585), p = 0.004 

Role-physical: 4.52 (95% CI, 0.519–8.516), 

p = 0.027 

Bodily pain: 3.10 (95% CI, 0.508–5.698), 

p = 0.019 

General health: 5.32 (95% CI, 3.027–7.611), 

p = 0.000 

Vitality: 5.41 (95% CI, 3.348–7.469), 

p = 0.000 

Social functioning: 4.36 (95% CI, 1.015–6.810), 

p = 0.000 

Role-emotional: 4.77 (95% CI, 0.960–8.588), 

p = 0.014 

Mental health: 5.13 (95% CI, 3.401–6.907), 

p = 0.000 

—

Table 5.1 Cross-sectional studies about smoking status and quality of life

The Benefits of Smoking Cessation on Overall Morbidity, Mortality, and Economic Costs 441
Study Design/population Smoking status Health status measure Outcomes/findings Comments

Olufade et al. 

(1999)

• Cross-sectional 

study conducted as 

a pilot test of SCQoL 

questionnaire

• Convenience sample 

of smokers and 

former smokers,

18 years of age 

and older at 

health clinics

• n = 101

• 1997–1998

• United States

• Current smokers 

(n = 75)

• Former smokers, 

smokefree for

≥2 weeks (n = 23)

• SF-36

• SCQoL

• Compared with current smokers, former 

smokers had significantly higher scores on 

physical functioning, vitality, general health, 

and PCS-36, but they showed no significant 

differences on other SF-36 measures

• Compared with current smokers, former 

smokers had significantly higher scores on 

SCQoL measures of self-control, sleep, and 

anxiety, but they did not differ on social 

interactions or cognitive functioning

• SF-36, mean difference (former smoker vs. 

current smoker) by QoL dimension:

– Physical functioning: 15.7, p <0.05

– Role-physical: 13.5, p >0.05

– Role-emotional: 11.3, p >0.05

– Vitality: 15.1, p <0.05

– Mental health: 7.4, p >0.05

– Social functioning: 5.4, p >0.05

– Bodily pain: 2.9, p >0.05

– General health: 21.5, p <0.01

– PCS-36: 6.1, p <0.05

– MCS-36: 3.4, p >0.05

• SCQoL, mean difference (former smoker vs. 

current smoker) by QoL dimension:

– Social interactions: 7.9, p >0.05

– Self-control: 45.2, p <0.01

– Sleep: 15.1, p <0.01

– Cognitive functioning: 9.7, p >0.05

– Anxiety: 15.2, p <0.05

—

A Report of the Surgeon General

442 Chapter 5

Table 5.1 Continued
Study Design/population Smoking status Health status measure Outcomes/findings Comments

Mulder et al. 

(2001)

•

•

•

•

•

Cross-sectional 

study

Random sample 

of the general 

population, 20–59

years of age without 

a history of smokingrelated chronic 

diseases

n = 9,660

1995–1997

The Netherlands

•

•

•

Never smokers

Ex-smokers

Current smokers

• RAND-36 (adapted 

from SF-36)

•

•

•

•

•

Ex-smokers reported significantly higher 

QoL scores than current smokers for all QoL 

dimensions (p <.05), except for bodily pain

Adjusted mean scores on QoL measures did 

not differ significantly between never smokers 

and ex-smokers, except for bodily pain 

(p <0.0001)

A higher number of years since quitting was 

associated with higher scores on general 

health, vitality, mental health, and the MCS

Differences in QoL scores between ex-smokers 

and current smokers were more pronounced 

for QoL dimensions reflecting mental health 

than physical health

No significant trend was observed for time 

since quitting

—

Table 5.1 Continued

The Benefits of Smoking Cessation on Overall Morbidity, Mortality, and Economic Costs 443
Study Design/population Smoking status Health status measure Outcomes/findings Comments

Bellido-Casado 

et al. (2004)

• Cross-sectional 

study

• Representative 

sample of the general 

population older 

than 14 years of age

• n = 265

• 1997–2000

• Spain

• Smokers

• Nonsmokers

• Former smokers

• SF-36 • No statistically significant differences by 

smoking status in measures of physical health 

(p = 0.682) or emotional health (p = 0.430)

• Physical QoL dimensions—mean scores 

(95% CI):

– Physical function:

 Smokers: 86.92 (83.14–90.71)

 Former smokers: 89.09 (84.74–93.44)

– Role-emotional:

 Smokers: 86.81 (78.79–94.83)

 Former smokers: 89.57 (80.35–98.79)

– Bodily pain:

 Smokers: 68.24 (62.36–74.13)

 Former smokers: 67.22 (60.46–73.99)

– General health:

 Smokers: 59.54 (54.72–64.36)

 Former smokers: 61.24 (55.71–66.78)

• Emotional QoL dimensions—mean scores 

(95% CI):

– Vitality:

 Smokers: 59.07 (53.32–64.83)

 Former smokers: 63.55 (56.94–70.17)

– Social function:

 Smokers: 83.66 (78.10–89.22)

 Former smokers: 88.00 (81.60–94.39)

– Role-emotional:

 Smokers: 79.44 (69.01–89.87)

 Former smokers: 84.67 (72.68–96.66)

– Mental health:

 Smokers: 71.99 (66.90–77.08)

 Former smokers: 74.33 (68.48–80.18)

Adjusted for age, 

sex, social class,

alcohol consumption, 

accumulated 

exposure to tobacco, 

diurnal sleepiness, 

number of known 

risk factors, and BMI

Table 5.1 Continued

A Report of the Surgeon General

444 Chapter 5
Study Design/population Smoking status Health status measure Outcomes/findings Comments

Mody and Smith 

(2006)

• Cross-sectional 

study

• Representative 

sample of 

noninstitutionalized 

adults from the 2001 

Behavioral Risk 

Factor Surveillance 

System

• n = 209,031

• 2001

• United States

• Nonsmokers 

(n = 108,072)

• Current smokers 

(n = 48,096)

• Ex-smokers 

(n = 52,863)

• HRQoL measured 

by self-rated health 

status, number of 

days of poor physical 

health, number of 

days of poor mental 

health, and number 

of days of activity 

limitations

• Compared with ex-smokers, current smokers 

were (reported asORs): 

– 1.48 (95% CI, 1.32–1.65)times as likely 

toexperience ≥14 days of activity limitations 

in the past 30 days 

– 1.29 (no CI provided)times as likely to 

report poor general health 

– 1.30 (95% CI, 1.19–1.42)times as likely to 

report ≥14 days of poor physical health 

– 1.65 (95% CI, 1.50–1.81)times as likely to 

report ≥14 days of poor mental health 

Adjusted for age, 

sex, race, education 

level, marital status, 

annual household 

income, BMI, and 

presence of at least 

one comorbid disease

Heikkinen et al. 

(2008)

• Cross-sectional 

study

• Nationally 

representative 

sample of adults, 

30 years of age 

and older

• n = 8,028

• 2000–2001

• Finland

• Never smokers

• Daily smokers

• Occasional smokers

• Ex-smokers 

(reported not 

smoking for at 

least the past 

month)

• 15-D

• Overall QoL was 

assessed by a singlequestion measure 

that captured

the respondent’s 

perception and 

estimation of his 

or her QoL

• Ex-smokers reported higher scores than daily 

smokers on most dimensions of QoL

• Compared with men who smoked daily, men 

who were ex-smokers scored significantly 

higher in mobility, seeing, breathing, 

usual activities, discomfort and symptoms, 

depression, distress, and vitality (p <.05) and 

significantly lower in excreting (p <0.05)

• Compared with women who smoked daily, 

women who were ex-smokers scored 

significantly higher on breathing, eating, 

depression, distress, and vitality (p <0.05)

Adjusted for age

Table 5.1 Continued

The Benefits of Smoking Cessation on Overall Morbidity, Mortality, and Economic Costs 445
Study Design/population Smoking status Health status measure Outcomes/findings Comments

McClave et al. 

(2009)

(continues on 

next page)

•

•

•

•

Cross-sectional 

study

Representative 

sample of 

noninstitutionalized 

adults from the 2006 

Behavioral Risk 

Factor Surveillance 

System surveys in 

Delaware, Hawaii, 

Rhode Island, and 

New York

n = 17,800

United States

•

•

•

•

Never smokers 

(n = 9,149)

Former smokers 

(n = 5,522)

Nonquitters 

(n = 1,363)

Unsuccessful 

quitters (n = 1,766)

•

•

•

CDC HRQoL-14 

Healthy Days 

Symptoms Module

Self-rated general 

health status

Life dissatisfaction

•

•

•

•

•

Former smokers were less likely than 

nonquitters to report life dissatisfaction 

and frequent depressive symptoms

No significant differences were found in 

general health status, frequent anxiety 

symptoms, frequent mental distress, 

frequent physical distress, frequent activity 

limitations, frequent pain, infrequent 

vitality, and frequent sleep impairment

Among men, no significant differences 

in HRQoL were found between former 

smokers and nonquitters

Among women, unsuccessful quitters were 

more likely than current smokers to report

the frequent occurrence of mental distress, 

physical distress, and pain (p <.05)

OR (95% CI) by QoL dimension and 

smoking status:

– Fair/poor general health:





Former smoker: 1.1 (0.7–1.7)

Never smoker: 1.1 (0.7–1.7)

–

–

–

–

–

Life dissatisfaction:





Former smoker: 0.5 (0.3–0.9)

Never smoker: 0.4 (0.2–0.7)

Frequent anxiety symptoms:





Former smoker: 0.7 (0.5–1.1)

Never smoker: 0.5 (0.4–0.7)

Frequent depressive symptoms:





Former smoker: 0.7 (0.4–1.0)

Never smoker: 0.6 (0.4–1.0)

Frequent mental distress:





Former smoker: 1.3 (0.8–2.0)

Never smoker: 0.8 (0.5–1.3)

Frequent physical distress:





Former smoker: 1.3 (0.8–2.0)

Never smoker: 1.0 (0.6–1.5)

Adjusted for age, 

race/ethnicity, 

sex, education, 

marital status,

employment status, 

chronic disease, and 

healthcare coverage; 

unsuccessful quitters 

were respondents 

who had smoked at 

least 100 cigarettes 

in their lifetime, 

currently smoked 

every day or some 

days, and had 

abstained from 

smoking for 1 day 

or longer during the 

previous year in an 

unsuccessful attempt 

to quit smoking; and 

nonquitters were 

current smokers who

made no attempt 

to quit

Table 5.1 Continued

A Report of the Surgeon General

446 Chapter 5
Study Design/population Smoking status Health status measure Outcomes/findings Comments

(continued from 

previous page) 

McClave et al. 

(2009)

— — — – Frequent activity limitations:





Former smoker: 1.2 (0.7–2.1)

Never smoker: 0.8 (0.5–1.4)

– Frequent pain:





Former smoker: 1.3 (0.8–1.9)

Never smoker: 1.0 (0.7–1.4)

– Infrequent vitality:





Former smoker: 1.1 (0.8–1.5)

Never smoker: 1.1 (0.8–1.4)

– Frequent sleep impairment:





Former smoker: 0.8 (0.6–1.1)

Never smoker: 0.6 (0.4–0.8)

—

Table 5.1 Continued

The Benefits of Smoking Cessation on Overall Morbidity, Mortality, and Economic Costs 447

Notes: 15-D = 15 dimensions (generic, self-administered measure of HRQoL); BMI = body mass index; CDC = Centers for Disease Control and Prevention; CI = confidence 

interval; EuroQoL = European quality of life; HRQoL = health-related quality of life; MCS = Mental Component Summary; OR = odds ratio; PCS = Physical Component 

Summary; QoL = quality of life; SCQoL = Smoking Cessation Quality of Life; SF = Short Form (survey).
Study Design/population Smoking status Health status measure Outcomes/findings Comments

Stewart et al. 

(1995)

•

•

•

•

•

Cohort study from 

RCT of smoking 

cessation

Current smokers, 

18–65 years of 

age at the time of 

enrollment into

RCT, randomly

selected in California 

and abstinent for

24 hours at baseline

n = 323

United States

HRQoL follow-up at 

6 months; smoking 

status assessed at

3 and 6 months

•

•

Smokers: Had 

smoked within the 

last 7 days (n = 220)

Nonsmokers: 

Had not smoked 

within the past

7 days; confirmed 

with cotinine test 

(n = 103)

• Mental health:

–

–

–

–

–

–

–

–

–

Psychological wellbeing/distress

Depression/

behavioralemotional control

Anxiety

Positive affect

Cognitive

functioning

Energy/fatigue

Sleep adequacy

Self-esteem

Sense of mastery

• Physical health:

–

–

–

–

–

Physical 

functioning

Role functioning

Social functioning

Pain

Current health 

perceptions

•

•

•

•

•

Compared with smokers at 6 months, 

nonsmokers had:

Significantly higher scores on mental health 

dimensions

Significantly lower scores on physical and 

role functioning

No difference in scores on physical 

functioning, social functioning, pain, and 

current health perceptions

Mean difference (smokers vs. nonsmokers) at 

6 months by QoL component and dimension:

– Mental health:



















Psychological well-being/distress: 4.4, 

p <.05

Depression/behavioral–emotional control: 

4.9, p <.01

Anxiety: 7.7, p <.001

Positive affect: 4.2, p <.05

Cognitive functioning: 3.4, p <.05

Energy/fatigue: 6.6, p <.01

Sleep adequacy: 6.5, p <.05

Self-esteem: 3.6, p <.05

Sense of mastery: 9.3, p <.001

– Physical health:











Physical functioning: 0.8, p >.05

Role functioning: -6.0, p <.05 

Social functioning: -0.7, p >.05

Pain: 3.4, p >.05

Current health perceptions: 3.2, p >.05

For all QoL 

dimensions, except 

sleep adequacy, 

self-esteem, and 

sense of mastery,

adjusted for age, sex, 

ethnicity, education, 

employment status, 

marital status, 

number of chronic 

conditions, number of

cigarettes smoked at 

enrollment, nicotine 

dependence at 

enrollment, nicotine 

gum intervention, 

and initial assessment

of HRQoL; and for 

sleep adequacy, selfesteem, and sense of 

mastery dimensions, 

adjusted for all except

initial assessment 

of HRQoL; excluded 

those who had 

relapsed at 3 months 

but quit again 

by months and 

those who were not 

smoking at 3 months 

but were smoking at 

6 months

Table 5.2 Prospective studies about smoking status and quality of life

A Report of the Surgeon General

448 Chapter 5
Study Design/population Smoking status Health status measure Outcomes/findings Comments

Erickson et al. 

(2004)

• Short-term 

longitudinal 

cohort study

• Adults actively 

attempting to 

quit smoking

• n = 34

• 1999–2002

• United States

• Follow-up at 1 week 

after quitting

• Low addiction: 

FTND ≤6 (n = 22)

• High addiction: 

FTND >6 (n = 12)

• SCQoL questionnaire:

– HRQoL

– SF-36

• WPS

• Anxiety and cognitive functioning dimensions 

were significantly worse 1 week after quitting

• Self-control dimension improved significantly 

1 week after quitting

• SF-36 measure of general health showed a 

significant improvement 1 week after quitting.

• WPS score was lower 1 week after quitting 

but was not significant

• Low-addiction group had higher HRQoL 

at baseline

• Compared with the high-addiction group, 

the low-addiction group showed a significant 

improvement in more HRQoL domain scores 

after quitting

• SCQoL results by domain:

– Anxiety: p = 0.04

– Cognitive function: p = 0.02

– Self-control: p = 0.001

– Sleep: p = 0.15

– Social interaction: p = 0.34

• SF-36 results by domain:

– Bodily pain: p = 0.12

– General health: p = 0.01

– Mental health: p = 0.14

– Physical function: p = 0.27

– Role-emotional: p = 0.65

– Role-physical: p = 0.25

– Social function: p = 0.26

– Vitality: p = 0.53

• WPS: p = 0.17

—

Table 5.2 Continued

The Benefits of Smoking Cessation on Overall Morbidity, Mortality, and Economic Costs 449
Study Design/population Smoking status Health status measure Outcomes/findings Comments

Gutiérrez-Bedmar 

et al. (2009)

• Cohort study

• University graduates

• n = 5,234

• 1999–2006

• Spain

• Follow-up at 4 years

• Baseline:

– Nonsmokers 

(n = 2,639)

– Ex-smokers 

(n = 1,419)

– Smokers 

(n = 1,048)

• Follow-up:

– Nonsmokers 

(n = 3,594)

– Smokers (n = 818)

– Recent quitters 

(n = 435)

– Starters (n = 205)

• SF-36 (validated 

Spanish version)

• Ex-smokers had significantly lower mean 

scores on the SF-36 than nonsmokers in two 

QoL dimensions: role-physical and bodily pain

• Ex-smokers had significantly higher scores 

than smokers of 15–24 cigarettes per day in 

two QoL dimensions: general health and 

role-emotional

• Ex-smokers had significantly higher scores 

than smokers of ≥25 cigarettes per day in 

four QoL dimensions: general health, social

• functioning, role-emotional, and mental health

• At follow-up, the recent quitters group had 

significantly better mean scores than smokers 

in two QoL dimensions: general health and 

role-emotional

Adjusted for age 

and sex

Tian et al. (2016) • Cohort study

• 25-year follow-up 

of participants in 

a previous cohort, 

23–34 years of age 

at enrollment

• n = 2,080

• 2001–2011

• Australia

• Follow-up at 2 and 

5 years

• Baseline smoking 

status:

– Never smoker

– Former smoker

– Current smoker

• Change in smoking 

status:

– Stable, never 

smokers

– Stable, former 

smokers

– Resumed

– Continuing

– Quitter

• SF-12 PCS and MCS • No significant differences in HRQoL 

dimensions at baseline between never and 

former smokers.

• Continuing smokers had larger reductions 

than quitters

• The risk of clinically significant improvement 

in physical HRQoL was higher for quitters 

than for continuing smokers

• Clinically meaningful improvement in PCS 

(quitters vs. continuing): RR = 1.43 (95% CI, 

1.03–1.98)

• Mean difference, baseline PCS (former smokers 

vs. never smokers): -0.49 (95% CI, -1.32–0.34)

• Mean difference, baseline MCS (former smokers 

vs. never smokers): -0.36 (95% CI, -1.31–0.60)

Adjusted for age, sex, 

marital status, followup duration, baseline 

PCS, residing in a 

major city, education 

level, BMI, IPAQ level, 

total alcoholic drinks 

per day, and diagnosis 

of current severe 

psychological distress

Table 5.2 Continued

A Report of the Surgeon General

450 Chapter 5

Notes: BMI = body mass index; CI = confidence interval; FTND = Fagerström Test for Nicotine Dependence; HRQoL = health-related quality of life; IPAQ = International 

Physical Activity Questionnaire; MCS = Mental Component Summary; PCS = Physical Component Summary; QoL = quality of life; RCT = randomized controlled trial; 

RR = relative risk; SCQoL = Smoking Cessation Quality of Life; SF = Short Form (survey); WPS = Work Performance Scale.
Study Design/population Smoking status Health status measure Outcomes/findings Comments

Bolliger et al. 

(2002)

•

•

•

•

•

Cohort study from 

RCT of oral nicotine 

inhaler for smoking 

reduction

Healthy adult 

volunteers, unable 

or unwilling to 

stop smoking 

immediately, 

randomized to 

active or placebo 

inhalers for 

18 months and 

encouraged to 

reduce smoking as 

much as possible

n = 400

Switzerland

Follow-up for 

24 months

•

•

Successful reducers: 

Reduction of daily 

cigarettes of at least 

50% from week 6 to 

month 24 (n = 25)

Control group:

Failed to reduce 

smoking or carbon 

monoxide output, 

or failed to attend

one or more of seven 

follow-up visits

(n = 285)

• SF-36: General 

health, physical 

functioning, energy, 

and emotional

well-being

•

•

•

•

Significantly greater improvement in general 

health was seen in successful reducers 

compared with those in the control group

Among successful reducers, physical 

functioning showed nonsignificant t trend 

toward greater improvement

Emotional well-being and energy improved 

more in the successful reducers than among 

those in the control group, but the difference 

was not significant

Mean change from baseline by QoL dimension 

and smoking status:

– General health:







Successful reducer: 9.4

Control group: 2.3

p = 0.049

– Physical functioning:







Successful reducer: 7.4

Control group: 4.9

p = 0.073

– Energy:







Successful reducer: 6.8

Control group: 5.3

p = 0.23

– Emotional well-being:







Successful reducer: 6.2

Control group: 4.2

p = 0.50

—

Table 5.3 Prospective studies of populations undergoing cessation treatment

The Benefits of Smoking Cessation on Overall Morbidity, Mortality, and Economic Costs 451
Study Design/population Smoking status Health status measure Outcomes/findings Comments

Zillich et al.

(2002)

• Cohort study

• Adult smokers

interested in quitting 

and enrolled in a 

pharmacist-based 

smoking cessation 

program

• n = 31

• 2000–2001

• United States

• Follow-up at

• 6 months

• Smoker

• Abstinent: Selfreported abstinence 

during the previous 

7 days confirmed 

with exhaled carbon

monoxide test

• SCQoL questionnaire • Among those who reported abstinence, there 

were statistically significant improvements 

for vitality, mental health, and self-control

at 3 months (p <.05)

SCQoL missing for

those who did not

report abstinence

Croghan et al. 

(2005)

• Cohort study

• Patients undergoing 

treatment for 

nicotine 

independence

• n = 206

• 1998

• United States

• Follow-up for 1 year

• Abstinent ≤6 days 

(n = 60)

• Continuously 

abstinent for entire

year (n = 146)

• SF-36 • Compared with those who were not 

continuously abstinent for a year, those 

who were continuously abstinent for a year 

reported significantly improved MCS, role 

limitations-emotional, role limitationsphysical, and general health

Controlled for scores

at baseline; mean 

scores not reported

Rungruanghiranya 

et al. (2008)

• Placebo-controlled 

RCT for effectiveness 

of nicotine gum

• n = 43

• Thailand

• Follow-up at

• 3 months

• Abstinence failure 

(n = 31)

• Abstinence 

successful: Complete 

and continuous 

abstinence for

3 months (n = 12)

• WHOQoL-BREF • No significant differences in QoL scores were 

observed between those who successfully quit

and those who failed

—

Table 5.3 Continued

A Report of the Surgeon General

452 Chapter 5
Study Design/population Smoking status Health status measure Outcomes/findings Comments

Hays et al. 

(2012)

• Placebo-controlled 

RCT ofvarenicline

and bupropion 

sustainedrelease

• Adults who 

had smoked

≥10 cigarettes per

day for the past year

• n = 2,052

• 2003–2005

• United States

• Follow-upfor 1 year

• Adults who

had smoked

• ≥10 cigarettes per 

day for the past year

• SCQoL • Both treatment groups showed clinically 

relevant differences in health transition and 

self-control at 1 year

• Those with longer periods of abstinence 

reported better health transition, self-control, 

vitality, smoking-related anxiety, and MCS 

than those with shorter periods of abstinence

—

Piper et al. (2012) • Cohort study from 

RCT of smoking 

cessation treatments

• n = 1,504

• 2005–2007

• United States

• Follow-upfor3

years

• Non-quitter

• Quitter: 7-day

point prevalence

confirmed with 

carbon monoxide 

test

• QoL Inventory • Compared with nonquitters, quitters reported 

significantly lower QoL scores at years 1 and 3

• Compared with continuing smokers, quitters 

showed improved global QoL, HRQoL, and 

affect at years 1 and 3 and fewer stressors

by year 3

—

Table 5.3 Continued

The Benefits of Smoking Cessation on Overall Morbidity, Mortality, and Economic Costs 453

Notes: MCS = Mental Component Summary; QoL = quality of life; RCT = randomized controlled trial; SCQoL = Smoking Cessation Quality of Life; SF = Short Form (survey); 

WHOQoL-BREF = World Health Organization Quality of Life-BREF.
Study Design/population Smoking status Health status measure Outcomes/findings Comments

Taira et al. (2000) •

•

•

•

•

Cohort study of 

RCT of atherectomy 

techniques

Patients who 

underwent 

percutaneous 

coronary 

revascularization 

for coronary 

artery disease

n = 1,432

United States

Follow-up for 1 year

•

•

•

Nonsmokers

Persistent smokers

Quitters

• SF-36 •

•

•

•

All groups showed improvement on 

dimensions of the SF-36, but persistent 

smokers showed a smaller improvement 

than nonsmokers across all dimensions

Quitters showed improvement equal to or 

better than nonsmokers across all dimensions

Persistent smokers showed significantly less 

improvement than quitters in three QoL 

dimensions: physical functioning, social 

functioning, and mental health

Mean difference byQoL dimension and 

follow-up period:

–

–

–

–

–

–

–

–

Physical functioning:





6 months: 8.4 (p <0.001)

1 year: 5.8 (p = 0.01)

Role-physical:





6 months: 10.3 (p <0.001)

1 year: 6.2 (p = 0.14)

Bodily pain:





6 months: 4.2 (p <0.001)

1 year: 2.9 (p = 0.25)

General health:





6 months: 5.5 (p = 0.001)

1 year: 4.0 (p = 0.07)

Vitality:





6 months: 5.2 (p <0.001)

1 year: 2.7 (p = 0.25)

Social functioning:





6 months: 7.5 (p <0.001)

1 year: 6.0 (p = 0.01)

Role-emotional:





6 months: 3.7 (p = 0.039)

1 year: 0.1 (p = 0.92)

Mental health:





6 months: 3.7 (p <0.001)

1 year: 3.8 (p = 0.05)

Adjusted for 

demographic 

and clinical 

characteristics,

comorbid conditions, 

and baseline 

health status

Table 5.4 Prospective studies of special populations

A Report of the Surgeon General

454 Chapter 5
Study Design/population Smoking status Health status measure Outcomes/findings Comments

Mitra et al. (2004) • Longitudinal 

survey of adults 

with disabilities 

(Massachusetts

Survey of Secondary 

Conditions)

• n = 355

• 1996–2000

• Massachusetts

• Nonsmokers

• Smokers

• Quitters

• Starters

• SF-36 (enabled version) • Compared with smokers, quitters experienced

• significantly more improvement in mental 

health, energy and vitality, and general 

health perception

Adjusted for sex, 

race/ethnicity, years 

of education, age at 

baseline, number of 

QoL dimensions on 

which respondents 

were dependent 

on activities of daily 

living

Wiggers et al. 

(2006)

•

•

•

•

•

RCT of nicotine 

replacement therapy 

and behavioral 

intervention

Patients with 

symptomatic 

atherosclerotic 

disease

n = 344

The Netherlands

Follow-up for 1 year

•

•

•

Smokers with a 

failed quit attempt

Smokers without a 

failed quit attempt

Quitters

•

•

•

SF-36

Aquarel

VascuQoL

• Study found no effects of smoking status 

on QoL

—

Jensen et al.

(2007)

• Longitudinal cohort 

study

• Patients after radical 

radiotherapy or 

surgery for head 

and neck cancer 

• n = 114 

• Denmark 

• Never smokers

• Smokers

• Quitters

• EORTC-C30

• EORTC-H&N35

• Compared with smokers, those who had quit 

smoking at follow-up showed higher physical 

and mental functioning

• The QoL scores of quitters fell between those 

of never smokers and smokers

—

Table 5.4 Continued

The Benefits of Smoking Cessation on Overall Morbidity, Mortality, and Economic Costs 455
Study Design/population Smoking status Health status measure Outcomes/findings Comments

Balduyck et al. 

(2011)

• Cohort study

• Patients undergoing 

non-small-cell lung 

cancer surgery

• n = 70

• Belgium

• Follow-up for 12 

months

• Nonsmokers

• Former smokers 

(stopped smoking 

before diagnosis 

of lung cancer)

• Recent quitters 

(patients who 

stopped smoking 

between diagnosis 

and surgery)

• EORTC-C30

• EORTC-LC13

• All groups had a reduction in QoL after surgery, 

but those who were former smokers at baseline 

and those whoquit smoking after diagnosis 

showed improved QoL scores at follow-up 

compared with those who continued smoking

—

Papadopoulos 

et al. (2011)

• Longitudinal 

cohort study

• Patients with COPD 

who smoked and 

were recommended 

to quit smoking

• Greece

• n = 26

• Follow-up for 2 

months

• Smokers

• Quitters

• SF-12

• CCQ

• Thosewho successfully quit smoking for

2 months showed significant differences in all 

domains of the SF-12 and in total CCQ score 

from baseline

• CCQ total score:

– Before: 1.08 ± 0.82

– Follow-up: 0.72 ± 0.69

– p <0.001

—

Table 5.4 Continued

A Report of the Surgeon General

456 Chapter 5

Notes: CCQ = Clinical COPD Questionnaire; COPD = chronic obstructive pulmonary disease; EORTC-C30 = European Organization for Research and Treatment of Cancer 

Quality of Life Questionnaire, Core Module; EORTC-H&N35 = European Organization for Research and Treatment of Cancer Quality of Life Questionnaire, Head and 

Neck Module; EORTC-LC13 = European Organization for Research and Treatment of Cancer Quality of Life Questionnaire, Lung Cancer Module; QoL = quality of life; 

RCT = randomized controlled trial; SF = Short Form (survey); VascuQoL = Vascular Quality of Life (questionnaire).
The Benefits of Smoking Cessation on Overall Morbidity, Mortality, and Economic Costs 457

Smoking Cessation

All of the studies determined whether participants 

were former smokers, but the period of abstinence from 

smoking required for classification as a former smoker was 

not uniform across studies, and some studies did not specify 

a minimum time period of abstinence (McClave et al. 2009; 

Tian et al. 2016). Some studies confirmed smoking status by 

a biomarker, such as cotinine (Stewart et al. 1995) or carbon 

monoxide (Zillich et al. 2002; Rungruanghiranya et al. 2008; 

Hays et al. 2012; Piper et al. 2012). Several studies (Stewart 

et al. 1995; Croghan et al. 2005; Wiggers et al. 2006; Piper 

et al. 2012) defined abstinence as a period of 7 days without 

smoking, but others used different standards, including 

2 weeks (Olufade et al. 1999), 1 month (Mitra et al. 2004; 

Heikkinen et al. 2008), 3 months (Rungruanghiranya et al. 

2008), and 5 years (Tillmann and Silcock 1997). One study, 

Erickson and colleagues (2004), considered level of addiction and divided former smokers into subgroups of low 

and high addiction, as assessed by the Fagerström Test for 

Nicotine Dependence (FTND) (Heatherton et al. 1991).

Some variation was also observed with regard to 

comparison groups used across studies. For example, as 

the reference group for comparing outcomes among those 

who had quit successfully, McClave and colleagues (2009) 

used unsuccessful quitters, defined as those who had 

attempted to quit at least once in the past year but were 

currently smoking. In a clinical trial of nicotine replacement therapy (NRT), Bolliger and colleagues (2002) compared successful reducers, who were ongoing smokers 

who had achieved at least a 50% reduction in the number 

of cigarettes smoked daily from week 6 to month 24 of the 

trial, with unsuccessful reducers.

Epidemiologic Evidence

Cross-Sectional Studies

Table 5.1 summarizes cross-sectional studies of 

smoking cessation and morbidity. Seven cross-sectional 

studies assessed smoking cessation and morbidity by 

asking participants to self-report smoking status and a 

measure of morbidity at the time of survey. Several studies 

that used the SF-36 to assess HRQoL observed that having 

quit smoking was associated with higher scores on some 

measures. Tillmann and Silcock (1997), in a study of 

3,000 participants, reported significantly higher HRQoL, 

as measured by SF-36 and EuroQoL tariff scores, among 

former smokers who had smoked 5 years or more compared with current smokers in Scotland. Olufade and colleagues (1999), in a sample of 101 adults, reported that 

former smokers (smokefree for 2 or more weeks) had significantly higher scores on physical functioning, vitality, 

general health, and the Physical Component Summary 

compared with current smokers; however, they found no 

significant differences for other measures on the SF-36. In 

the Netherlands, Mulder and colleagues (2001) reported 

significantly higher HRQoL scores for former smokers on 

all measures of the SF-36, except bodily pain compared 

with current smokers. In their sample, the HRQoL of 

former smokers approached that of never smokers, and 

adjusted mean scores on measures of the SF-36 did not 

differ significantly between never smokers and former 

smokers, except for bodily pain. Mulder and colleagues 

(2001) also found that increasing years since quitting was 

associated with higher scores on general health, vitality, 

mental health, and the Mental Component Summary. 

These researchers noted that overall differences in QoL 

between former smokers and current smokers were more 

pronounced for measures of mental health than for physical health. Although the first three studies found various 

differences by smoking status using the SF-36, in a representative sample of adults older than 14 years of age 

in Spain, Bellido-Casado and colleagues (2004) found no 

differences by smoking status in measures of physical, 

emotional, or mental health in the SF-36.

Two studies used data from the Behavioral Risk 

Factor Surveillance System (BRFSS), a telephone-based 

survey of U.S. adults 18 years of age and older. In an analysis of data from 2001 from a representative sample of 

209,031 adults, Mody and Smith (2006) found that, compared with nonsmokers and former smokers, current 

cigarette smokers were more likely to experience (in the 

past 30 days) 14 or more days of activity limitation, 14 or 

more days of poor physical health, and 14 or more days of 

poor mental health. In addition, in their comparisons with 

former smokers, they found that current smokers were 

more likely to report poor general health. McClave and 

colleagues (2009), who used BRFSS data from 2006 in four 

states, found that former smokers and nonsmokers were 

less likely than current smokers (nonquitters) to report 

life dissatisfaction and frequent depressive symptoms; 

however, there were no significant differences between 

current and former smokers in reported general health 

status, frequent anxiety symptoms, frequent mental distress, frequent physical distress, frequent activity limitations, frequent pain, infrequent vitality, or frequent sleep 

impairment. Among men, there were no significant differences in HRQoL between former and current smokers. 

Among women, reported frequent mental and physical 

distress did not differ significantly between former and 

never smokers and current smokers, but among current 

smokers, women who tried to quit smoking and failed 

were more likely to report frequent mental stress and 

physical distress than were women who did not try to quit.

Heikkinen and colleagues (2008) used the 15-D instrument to assess HRQoL in a nationally representative sample 
A Report of the Surgeon General

458 Chapter 5

of about 8,000 adults 30 years of age and older in Finland. 

Compared with daily smokers, former smokers (defined 

as those who had not smoked for at least the past month) 

reported higher scores on most measures of the instrument.

Longitudinal Studies

Tables 5.2–5.4 summarize findings from 16 longitudinal studies of smoking cessation and general morbidity. 

These studies fall into three categories: (1)  prospective 

cohort studies, (2)  randomized controlled trials (RCTs), 

and (3)  observational studies embedded within RCTs in 

which the data from the RCTs were analyzed as though 

the studies were observational without preservation of the 

randomization. With these types of longitudinal designs, 

smoking status is assessed before the outcome occurs. In 

contrast, cross-sectional studies assess smoking status 

and the outcome at the same point in time. Prospective 

studies were considered for quality of life (Table 5.2), populations receiving cessation treatment (Table  5.3), and 

populations with specific medical conditions (Table 5.4). 

Studies included in Table  5.2 were all designed as prospective cohorts (Stewart et al. 1995; Erickson et al. 2004; 

Gutiérrez-Bedmar et al. 2009; Tian et al. 2016). Table 5.3 

includes studies with different longitudinal designs: prospective cohort (Zillich et al. 2002; Croghan et al. 2005), 

RCT (Rungruanghiranya et  al. 2008; Hays et  al. 2012), 

and observational study within an RCT (Bolliger et  al. 

2002; Piper et  al. 2012). Table  5.4 includes longitudinal 

studies designed as prospective cohorts (Taira et al. 2000; 

Mitra et al. 2004; Jensen et al. 2007; Balduyck et al. 2011; 

Papadopoulos et al. 2011) or observational studies within 

an RCT (Wiggers et al. 2006).

Longitudinal Studies of General Populations

At the 4-year follow-up of 5,234 participants of a 

study based in Spain, Gutiérrez-Bedmar and colleagues 

(2009) found that compared with current smokers, mean 

scores for general, emotional, and mental health were significantly better among recent former smokers who had 

quit after the baseline assessment and before the 4-year 

follow-up. Tian and colleagues (2016) assessed HRQoL, 

using the SF-12, in relation to smoking status at baseline 

(never, former, and current smokers) and after 5 years of 

follow-up in about 2,000 Australian adults 31–41 years of 

age at follow-up. There were no significant differences in 

measures comparing never and former smokers at baseline, but at the 5-year follow-up, those who had continued 

to smoke had larger reductions in QoL scores than those 

who reported being former smokers at follow-up and were 

smokers at baseline. For these quitters, the estimated relative risk for a clinically significant improvement in physical HRQoL scores was higher compared with continuing 

smokers. Additionally, former smokers had a higher likelihood of a clinically significant improvement in emotional and mental health HRQoL scores compared with 

continuing smokers.

Longitudinal Studies of Populations 

Undergoing Cessation Treatment

Eight trials considered participants engaged in cessation treatment. In one, Stewart and colleagues (1995) 

assessed the smoking status of 323 adults enrolled in a 

community-based RCT of smoking cessation. At baseline, all participants were smokers. At 6 months, quitters 

had a significantly higher score on all assessed measures 

of mental health compared with continuing smokers, 

including psychological well-being, anxiety, positive 

affect, cognitive functioning, energy, sleep adequacy, selfesteem, and sense of mastery. In contrast, for the five measures of physical health, there were no statistically significant differences between the groups on four measures: 

physical functioning, social functioning, pain, and current 

health perceptions.

Zillich and colleagues (2002) used the SCQoL questionnaire to evaluate changes in HRQoL among 31 participants in a nonrandomized, unblinded trial to evaluate the 

effectiveness of a pharmacist-based smoking cessation program. Vitality, mental health, and self-control improved 

significantly among those who successfully quit over the 

6 months of follow-up compared with baseline. However, 

data were missing for participants who did not successfully quit and did not return for follow-up. In Switzerland, 

Bolliger and colleagues (2002) enrolled a cohort of 

400 participants from an earlier RCT of an oral nicotine 

inhaler for smoking reduction and examined QoL in relation to smoking reduction. Healthy adult volunteers were 

randomized to active or placebo inhalers and encouraged 

to reduce their smoking as much as possible; the cohort 

was followed for 24  months. The comparison group of 

nonreducers (less than a 50%  reduction in the number 

of cigarettes smoked daily from week 6 to month 24) was 

used for comparison with successful reducers (at least a 

50% reduction). Compared with the control group, successful reducers had significantly greater improvement in 

general health, as measured by the SF-36.

Among those who quit in a study of 34 smokers, 

Erickson and colleagues (2004) considered whether low 

(FTND score ≤6) or high (FTND score >6) levels of addiction affected QoL 1  week after the quit date. The lower 

addiction group showed a significant improvement in 

more of the HRQoL domain scores after the quit date 

compared with the higher addiction group.

Croghan and colleagues (2005) evaluated 206 patients 

treated for nicotine dependence for changes in their health 

status, as measured by the SF-36, 1 year after consultation 
The Benefits of Smoking Cessation on Overall Morbidity, Mortality, and Economic Costs 459

Smoking Cessation

at the Mayo Clinic. Patients who stopped smoking for 1 year 

or more had significantly higher QoL measures at baseline 

compared with a demographically similar group who had 

not stopped smoking. After controlling for baseline scores, 

patients who stopped smoking for 1 year or more had significantly improved scores on the Mental Component 

Summary and for role limitations, both emotional and 

physical, and significantly improved general health compared with those who were not abstinent for a year.

Rungruanghiranya and colleagues (2008) performed 

a placebo-controlled RCT in Thailand that considered the 

effectiveness of nicotine gum for cessation and examined 

changes in QoL after 3 months. Forty-six subjects underwent screening for the study; two were excluded because 

of NRT use, and one was excluded due to a recent diagnosis 

of diabetes. Among the 43 participants, the study revealed 

no significant differences in improved QoL between those 

who had successfully quit smoking and those who had not.

Piper and colleagues (2012) assessed QoL in 

1,504 participants making a quit attempt as part of an RCT 

of smoking cessation. Both former smokers (i.e., quitters) 

and current smokers (nonquitters) experienced a reduction 

in global QoL at the 1- and 3-year follow-ups, but former 

smokers had a significantly smaller decrease in global QoL. 

Former smokers showed slight improvement in HRQoL 

at years 1 and 3, an outcome significantly different from 

the decreases in HRQoL reported by continuing smokers. 

Former smokers also reported a decrease in negative 

affect at 1 year, which differed significantly from the slight 

increase in continuing smokers.

Hays and colleagues (2012) implemented a placebocontrolled RCT in which 2,052 participants were treated 

with varenicline, bupropion SR (sustained release), or 

placebo and followed for 52  weeks. Participants in both 

treatment groups showed clinically relevant differences in 

health transition (perceived health compared with baseline) and self-control at follow-up compared with participants in the placebo group at follow-up. In terms of abstinence, those who had a longer period of abstinence reported 

better health transition and self-control at follow-up compared with those who were abstinent for a shorter period. 

Among those with a longer period of abstinence, findings 

were similar to those abstinent for a shorter period of time 

for vitality, smoking-related anxiety, and improvement in 

scores on the Mental Component Summary.

Longitudinal Studies of Special Populations

Table 5.4 summarizes six longitudinal studies that 

considered smoking cessation in special populations 

defined by disease status. Taira and colleagues (2000) 

assessed QoL after percutaneous coronary revascularization in 1,432 patients with coronary artery disease within 

two RCTs (Baim et al. 1998, 2001). All groups (nonsmokers, 

former smokers [quitters], and persistent smokers) showed 

improvements on measures of the SF-3, but the extent of 

improvement differed by smoking status. At 6  months, 

after controlling for baseline scores on the SF-36, improvement among former smokers was comparable to that of 

nonsmokers. At 1  year, persistent smokers continued to 

show significantly less improvement than former smokers 

in physical functioning, social functioning, and mental 

health. Compared with continuing smokers, former 

smokers made significantly greater gains in both Physical 

Component Summary and Mental Component Summary 

scores at 6 months and 1 year.

Using data from Wilber and colleagues (2002), Mitra 

and colleagues (2004) performed a longitudinal study of 

355  adults with disabilities and found that changes in 

smoking status were associated with future changes in 

QoL scores—with former smokers experiencing significantly more improvement in mental health, energy and 

vitality, and perceived general health compared with current smokers. In the Netherlands, Wiggers and colleagues 

(2006) studied 344 smokers with atherosclerotic vascular 

disease who were participating in an RCT of NRT combined with a behavioral intervention, and considered both 

general (SF-36) and disease-specific QoL (Aquarel and 

VascuQoL). Overall, participants showed improved physical and mental QoL, as measured by SF-36 at follow-up 

(2, 6, and 12 months), but there were no differences by 

smoking status. In a study based in Denmark, Jensen and 

colleagues (2007) considered smoking status and QoL in 

114 patients surveyed after treatment for head and neck 

cancer. Those who had quit smoking at postsurgical 

follow-up showed higher physical and mental functioning 

compared with continuing smokers.

In Greece, Papadopoulos and colleagues (2011) 

investigated smoking cessation and QoL using a diseasespecific score (the Clinical COPD Questionnaire [CCQ]) 

in a cohort of 26  participants with chronic obstructive 

pulmonary disease who had successfully quit smoking 

for 2 months. QoL, as measured by both the CCQ and a 

generic scale (SF-12), improved after 2 months of cessation. Finally, Balduyck and colleagues (2011), in a study 

based in Belgium, considered 70 patients’ return-to-baseline QoL after surgery for lung cancer using a diseasespecific score (EORTC-C30 and EORTC-LC13) that was 

administered after a reduction in smoking following surgery in all three smoking status groups (current smoker, 

former smokers, and recent quitters). Those who were 

former smokers at baseline (i.e.,  before their diagnosis) 

and those who quit smoking after diagnosis both showed 

improved QoL at follow-up compared with those who 

continued to smoke, although those who were former 

smokers at baseline had a faster return to baseline QoL 

than recent quitters.
A Report of the Surgeon General

460 Chapter 5

Synthesis of the Evidence

Studies of morbidity and smoking cessation vary in 

their definitions of cessation, length of follow-up, and morbidity measures, including QoL. Nonetheless, despite these 

variations, the overall findings indicate that smoking cessation lessens general morbidity, specifically as measured 

by HRQoL and assessments of health status. Although the 

level of HRQoL for former cigarette smokers is between 

that of current smokers and never smokers, the HRQoL 

of former smokers approaches that of never smokers for 

many measures. This pattern is found in samples of the 

general population, in study participants undergoing cessation treatment, and in persons with specific diseases. 

Moreover, greater benefits have been found for measures of 

mental health than for measures of physical health. Some 

evidence suggests that persons with lower levels of addiction before cessation appear to experience greater gains in 

mental health, and those who are abstinent for a longer 

period show higher levels of improvement in mental health.

One critical factor to consider in interpreting the 

evidence on smoking cessation and health is the potential 

for reverse causation—that is, the presence of symptoms 

or a disease leading to a decision to quit. If that is the 

case, the rates of symptoms in cross-sectional data might 

be higher in former smokers than in current smokers. 

Even in prospective cohort studies, when changes in indicators of health are tracked over time, the causal direction 

may be difficult to ascertain, particularly if participants 

quit as symptoms develop or as their well-being declines. 

Randomized trials of cessation interventions are not subject to such temporal limitations; however, generalizability may be limited because the populations in these 

studies may not reflect smokers in general.

Temporal ambiguity is a particular concern in crosssectional studies that assess smoking status and morbidity at the same time. In these cases, a better HRQoL 

in former smokers than in current smokers may result 

from smoking cessation or be a contributing factor to 

successful smoking cessation. Additionally, lower HRQoL 

may reduce the ability to successfully quit smoking. One 

further complication in interpreting cross-sectional data 

is related to the motivation of smokers to quit because of 

the development of smoking-related symptoms of disease. 

This type of reverse causation generally tends to reduce 

associations of cessation with beneficial outcomes.

Longitudinal studies—including prospective cohort 

studies, RCTs, and observational studies within an RCT—

provide higher quality evidence with less opportunity for 

temporal ambiguity, and they can measure QoL at baseline before differences across groups classified by smoking 

status are assessed. However, smokers who do not quit 

may be less likely to remain in longitudinal studies during 

follow-up (Zillich et al. 2002). Regardless, as with the evidence considered in the 1990 Surgeon General’s report on 

the health benefits of smoking cessation (USDHHS 1990), 

the variety of measures used in studies of cessation can 

limit comparability and summarization across studies.

Summary of the Evidence

This section reviews evidence on smoking cessation 

and general morbidity using a variety of broad, nonspecific but validated measures, such as QoL indicators and 

health status and disease-specific measures. For the measures that are broad and nonspecific, the determinants of 

responses are multifactorial. Thus, some studies reviewed 

in this chapter attempted to address potential confounding. Based on consistent evidence across the studies 

reviewed (Tables 5.1 and 5.2), former smokers have less 

general morbidity than current smokers, as reflected in 

higher QoL scores and in multiple measures of health 

status. Confounding may have affected the results of some 

of the studies reviewed; however, confounding alone does 

not adequately explain the consistent finding of lower 

morbidity and higher QoL among former smokers compared with current smokers. Selection bias is also a potential concern if persistent smokers, particularly those who 

are ill, are less likely than quitters to remain in follow-up 

during longitudinal studies.

Despite such limitations, the evidence for lower 

morbidity and higher QoL among former smokers than 

among current smokers is strengthened by the higher 

levels of improvement in QoL seen among those who had 

abstained from smoking longer; such a finding supports 

a conclusion of causality. Former smokers tend to have 

higher morbidity than never smokers; and in some subgroups, the morbidity of former smokers can approach 

that of never smokers, such as among those with lower 

levels of addiction before cessation.

A causal link between smoking cessation and a 

decrease in general morbidity is supported by the biologic 

plausibility of the relationship. Active smoking drives various nonspecific processes of injury (e.g., inflammation), 

which lessen with the end of exposure to the toxins in 

tobacco smoke (USDHHS 2010). Because the morbidity 

measures addressed in the studies reviewed in this chapter 

are broad and nonspecific, a single mechanism cannot be 

invoked to explain the association between smoking cessation and reduction of general morbidity. However, many 

well-supported mechanisms link smoking cessation to 

improvements in more specific measures of health, such 

as disease-specific outcomes, thus underscoring the likelihood that those who quit smoking will have lower rates 

of morbidity.
The Benefits of Smoking Cessation on Overall Morbidity, Mortality, and Economic Costs 461

Smoking Cessation

Benefits of Smoking Cessation on All-Cause Mortality

Increased all-cause mortality is a well-established 

causal consequence of smoking (USDHHS 2004, 2014). 

Chapter 4 of this report (The Health Benefits of Smoking 

Cessation) summarizes disease risks from smoking and 

the changes in risk that follow smoking cessation for 

the major types of chronic diseases. This section briefly 

summarizes the well-documented and extensive scientific evidence on the health benefits of smoking cessation on all-cause mortality. The review is limited in 

scope because the topic has been extensively covered in 

prior reports.

Conclusions from Previous Surgeon 

General’s Reports

The 1964 Surgeon General’s report included a table 

on all-cause mortality with the findings of seven cohort 

studies. In a pioneering quantitative synthesis of the 

data from the seven studies, the ratio of deaths observed 

to deaths expected was 1.68:1 (USDHEW 1964). A contemporary analysis of the data from the 1964 Surgeon 

General’s report showed statistically significant increases 

in all-cause mortality in all of the studies (Figures 5.1a 

and 5.1b) (Schumacher et al. 2014). The 1964 Surgeon 

General’s report concluded that, “Cigarette smoking is 

associated with a 70 percent increase in the age-specific 

death rates of males, and to a lesser extent with increased 

death rates of females. The total number of excess deaths 

causally related to cigarette smoking in the U.S. population cannot be accurately estimated. In view of the 

continuing and mounting evidence from many sources, 

it is the judgment of the [Surgeon General’s Advisory 

Committee on Smoking and Health] that cigarette 

smoking contributes substantially to mortality from 

certain specific diseases and to the overall death rate” 

(USDHEW 1964, p. 31).

By the time of the 1964 report, evidence from five 

cohort studies showed lower risk for all-cause mortality in 

former smokers compared with current smokers, and data 

from several cohorts showed declining risk for death in 

former smokers, compared with current smokers, as the 

interval since cessation lengthened.

Subsequent Surgeon Generals’ reports (USDHEW 

1969, 1979; USDHHS 1989, 1990, 2004, 2014) have comprehensively covered this topic and published findings 

comparable to those in the 1964 Surgeon General’s report. 

In brief, using data from the American Cancer Society’s 

Cancer Prevention Study II, the 1990 Surgeon General’s 

report included lifetable analyses on the health benefits of 

smoking cessation, offering the following conclusions on 

all-cause mortality:

• “Former smokers live longer than continuing

smokers, and the benefits of quitting extend to

those who quit at older ages. For example, persons

who quit smoking before age 50 have one-half the

risk of dying in the next 15 years compared with

continuing smokers.

• Smoking cessation at all ages reduces the risk of

premature death.

• Among former smokers, the decline in risk of death

compared with continuing smokers begins shortly

after quitting and continues for at least 10  to

15 years. After 10 to 15 years of abstinence, risk of

all-cause mortality returns nearly to that of persons

who never smoked” (USDHHS 1990, p. 92).

The 2004 Surgeon General’s report extended these

findings by comprehensively documenting and updating 

the evidence on active smoking and disease, noting that 

“fortunately for former smokers, studies show that substantial risks of smoking can be reduced by successfully 

quitting at any age” (USDHHS 2004, p. 25). Furthermore, 

the report concluded that “quitting smoking has immediate as well as long-term benefits, reducing risks for disease caused by smoking and improving health in general” 

(USDHHS 2004, p. 25).

The 2014 Surgeon General’s report provided the 

most recent extensive review of the consequences of 

smoking on health and confirmed findings from previous 

reports in the series:

• “The evidence is sufficient to infer that cigarette

smoking increases risk for all-cause mortality in

men and women.

• The evidence is sufficient to infer that the relative

risk of dying from cigarette smoking has increased

over the last 50 years in men and women in the

United States” (USDHHS 2014, p. 641).

The 2014 Surgeon General’s report also compared

the relative risks for all-cause mortality in the American 

Cancer Society’s Cancer Prevention Studies I (1959–1965) 

and II (1982–1988) with those in a pooled analysis of five 

contemporary cohorts with follow-up through 2010. The 
A Report of the Surgeon General

462 Chapter 5

Figure 5.1a Incidence rate ratios for death from any cause, by smoking status

Figure 5.1b Incidence rate ratios for death from lung cancer, by smoking status

Source: Schumacher and colleagues (2014). Copyright © 2014, Massachusetts Medical Society. Reprinted with permission from 

Massachusetts Medical Society.

Note: CI = confidence interval. “Panel A shows incidence-rate ratios for death from any cause, and Panel B shows incidence-rate ratios 

for death from lung cancer. The incidence rate is the number of events per 100 person-years. Person-years were attributed such that 

the incidence-rate ratios were equal to the reported mortality ratios implicitly, assuming that data were based on a homogeneous age 

group. Standard errors were not affected, since they depend only on the number of observed deaths. Since no study-specific detailed 

tables of data on persons who did not smoke were available, the group of nonsmokers in this forest plot is larger than the one used by 

Cochran and hence contains more observed deaths; to correct for this, standard errors were inflated accordingly. The horizontal lines 

represent confidence intervals, with arrows indicating extensions of the intervals. Boxes represent estimated incidence-rate ratios, 

with the sizes of the boxes indicating the inverse variance of the respective studies. Diamonds represent the pooled incidence-rate 

ratio. The width of the diamonds represents the width of the 95% confidence interval of the pooled incidence-rate ratio” (Schumacher 

et al. 2014, p. 187).
The Benefits of Smoking Cessation on Overall Morbidity, Mortality, and Economic Costs 463

Smoking Cessation

comparison revealed rising relative risks for all-cause 

mortality among current smokers, both men and women, 

in the contemporary cohorts. Among former smokers, the 

relative risks were substantially lower in the contemporary cohorts compared with those in the earlier American 

Cancer Society cohorts. However, compared with never 

smokers, the relative risks for former smokers were higher 

in the contemporary cohorts compared with the earlier 

cohorts (Tables 5.5a and 5.5b).

The 2014 Surgeon General’s report also found that 

despite advancement in disease prevention and treatment 

over the past 50 years, current cigarette smokers had not 

experienced as much improvement in life expectancy 

compared with former and never smokers. Former 

smokers had progressively lower relative risk of all-cause 

mortality the younger they quit smoking (USDHHS 

2014). For example, the Million Women Study found 

that women who quit smoking before 30 years of age and 

before 40 years of age avoided more than 97% and 90% of 

excess mortality risk, respectively, compared with those 

who continued smoking (Pirie et al. 2013). In an analysis 

of more than 216,000 adults from 1997 to 2004, Jha and 

colleagues (2013) found a similar relationship between 

smoking and survival: Smoking cessation before 40 years 

of age reduced the risk of death associated with continued 

smoking by approximately 90%. Additionally, adults who 

Table 5.5a Relative risks by smoking status and age group among adult men 35 years of age and older, United States

Current smokers (years of age) Former smokers (years of age)

35–54a 55–64b 65–74b ≥75b 35–54a 55–64b 65–74b ≥75b

Lung cancer 14.33 19.03 28.29 22.51 4.40 4.57 7.79 6.46

Other cancersc 1.74 1.86 2.35 2.18 1.36 1.31 1.49 1.46

Coronary heart disease 3.88 2.99 2.76 1.98 1.83 1.52 1.58 1.32

Other heart diseased — — 2.22 1.66 — — 1.32 1.15

Cerebrovascular disease — — 2.17 1.48 — — 1.23 1.12

Other vascular diseasese — — 7.25 4.93 — — 2.20 1.72

Diabetes mellitus — — 1.50 1.00 — — 1.53 1.06

Other cardiovascular diseasesf 2.40 2.51 — — 1.07 1.51 — —

Influenza, pneumonia, tuberculosis — — 2.58 1.62 — — 1.62 1.42

Chronic obstructive pulmonary diseaseg — — 29.69 23.01 — — 8.13 6.55

Influenza, pneumonia, tuberculosis, 

chronic obstructive pulmonary diseaseh

4.47 15.17 — — 2.22 3.98 — —

All causes 2.55 2.97 3.02 2.40 1.33 1.47 1.57 1.41

Source: Analyses of Cancer Prevention Study II and updated analyses of the pooled contemporary cohort population described in Thun 

and colleagues (2013) provided to the Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and 

Health Promotion, Office on Smoking and Health.

aRelative risks for 35–54 years of age were obtained from Cancer Prevention Study.

bRelative risks for 55–64 years of age, 65–74 years of age, and 75 years of age and older were obtained from merged contemporary cohorts 

(Thun et al. 2013).

cOther cancers consist of cancers of the lip, pharynx and oral cavity, esophagus, stomach, pancreas, larynx, cervix uteri (women), kidney 

and renal pelvis, bladder, liver, colon and rectum, and acute myeloid leukemia.

dOther heart disease is composed of rheumatic heart disease, pulmonary heart disease, and other forms of heart disease.

eOther vascular diseases are composed of atherosclerosis, aortic aneurysm, and other arterial diseases.

f

For 35–54 years of age and ages 55–64 years of age, other cardiovascular diseases are composed of other heart disease, cerebrovascular 

disease, other vascular diseases, and diabetes mellitus and were analyzed and reported as one category. A single relative risk based on 

combined conditions was used to compute smoking-attributable mortality. Relative risk based on combined conditions was used to 

compute smoking-attributable mortality in these age strata.

gChronic obstructive pulmonary disease is composed of bronchitis, emphysema, and chronic airways obstruction.

hFor 35–54 years of age and 55–64 years of age, influenza, pneumonia, tuberculosis, and chronic obstructive pulmonary disease 

were analyzed and reported as one category. A single relative risk based on combined conditions was used to compute smokingattributable mortality.
A Report of the Surgeon General

464 Chapter 5

had quit smoking at 25–34, 35–44, or 45–54 years of age 

gained about 10, 9, and 6 years of life, respectively, compared with those who continued smoking. These findings are consistent with those reported in the 2004 and 

2014 Surgeon General’s reports. Although smokers lose 

an estimated decade of life on average, smoking cessation 

by 40 years of age avoided more than 90% of the excess 

mortality caused by continued smoking (USDHHS 2004, 

2010; Pirie et al. 2013). Even quitting smoking by about 

60 years of age could reduce premature mortality by 40% 

(USDHHS 2004, 2010).

Summary of the Evidence

The health benefits of smoking cessation on allcause mortality have been systematically reviewed in previous Surgeon General’s reports (USDHHS 2004, 2014). 

The evidence published since the 1990 Surgeon General’s 

report continues to affirm that smoking cessation at any 

age reduces the risk of premature death (Jha et al. 2013; 

Pirie et al. 2013; USDHHS 2014). The relative risk for 

dying from smoking has increased over time, but the benefit of quitting persists.

Table 5.5b Relative risks by smoking status and age group among adult women 35 years of age and older, United States

Current smokers (years of age) Former smokers (years of age)

35–54a 55–64b 65–74b ≥75b 35–54a 55–64b 65–74b ≥75b

Lung cancer 13.30 18.95 23.65 23.08 2.64 5.00 6.80 6.38

Other cancersc 1.28 2.08 2.06 1.93 1.24 1.28 1.26 1.27

Coronary heart disease 4.98 3.25 3.29 2.25 2.23 1.21 1.56 1.42

Other heart diseased — — 1.85 1.75 — — 1.29 1.32

Cerebrovascular disease — — 2.27 1.70 — — 1.24 1.10

Other vascular diseasese — — 6.81 5.77 — — 2.26 2.02

Diabetes mellitus — — 1.54 1.10 — — 1.29 1.06

Other cardiovascular diseasesf 2.44 1.98 — — 1.00 1.10 — —

Influenza, pneumonia, tuberculosis — — 1.75 2.06 — — 1.28 1.21

Chronic obstructive pulmonary diseaseg — — 38.89 20.96 — — 15.72 7.06

Influenza, pneumonia, tuberculosis, 

chronic obstructive pulmonary diseaseh

6.43 9.00 — — 1.85 4.84 — —

All causes 1.79 2.63 2.87 2.47 1.22 1.34 1.53 1.43

Source: Analyses of Cancer Prevention Study II and updated analyses of the pooled contemporary cohort population described in Thun 

and colleagues (2013) provided to the Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and 

Health Promotion, Office on Smoking and Health.

aRelative risks for 35–54 years of age were obtained from Cancer Prevention Study.

bRelative risks for 55–64 years of age, 65–74 years of age, and 75 years of age and older were obtained from merged contemporary cohorts 

(Thun et al. 2013). Relative risks for other vascular diseases among women 55 years of age and older do not include data from the 

Women’s Health Initiative of the National Heart, Lung, and Blood Institute.

cOther cancers consist of cancers of the lip, pharynx and oral cavity, esophagus, stomach, pancreas, larynx, cervix uteri (women), kidney 

and renal pelvis, bladder, liver, colon and rectum, and acute myeloid leukemia.

dOther heart disease is composed of rheumatic heart disease, pulmonary heart disease, and other forms of heart disease.

eOther vascular diseases are composed of atherosclerosis, aortic aneurysm, and other arterial diseases.

f

For 35–54 years of age and ages 55–64 years of age, other cardiovascular diseases are composed of other heart disease, cerebrovascular 

disease, other vascular diseases, and diabetes mellitus and were analyzed and reported as one category. A single relative risk based on 

combined conditions was used to compute smoking-attributable mortality. Relative risk based on combined conditions was used to 

compute smoking-attributable mortality in these age strata.

gChronic obstructive pulmonary disease is composed of bronchitis, emphysema, and chronic airways obstruction.

hFor 35–54 years of age and 55–64 years of age, influenza, pneumonia, tuberculosis, and chronic obstructive pulmonary disease 

were analyzed and reported as one category. A single relative risk based on combined conditions was used to compute smokingattributable mortality.
The Benefits of Smoking Cessation on Overall Morbidity, Mortality, and Economic Costs 465

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Benefits of Smoking Cessation on Economic Costs

Cigarette smoking causes both substantial morbidity and premature mortality, resulting in significant 

economic costs for smokers and their families and very 

large costs for society in general (USDHHS 2004). Because 

smoking cessation reduces these costs, the comparative 

costs and benefits of treatments for smoking cessation will 

help to inform tobacco control strategies for different settings. In evaluating the economic dimensions of smoking 

cessation, consideration needs to be given to the specific 

costs and benefits generated by programs or policies that 

increase successful cessation. These costs and benefits, 

which extend into numerous sectors beyond healthcare, 

include the consequences for employment, such as lost 

productivity from active smoking, as well as for retirement benefits and pensions that may be transferred to 

never smokers and former smokers from early tobaccorelated death among sustained smokers who do not quit 

(National Cancer Institute and World Health Organization 

2016). This section focuses on the economic dimensions 

of smoking cessation, including the critical comparator: 

the costs of smoking.

Economic Costs of Smoking

The economic costs of an intervention or managing a health outcome represent the opportunity cost of 

resources used, which includes direct costs, productivity 

losses, and intangible costs. Direct costs include direct 

medical and nonmedical costs; productivity losses—often 

referred as indirect costs—include the costs associated 

with morbidity and premature mortality; and intangible 

costs include such difficult-to-monetize consequences as 

pain and suffering and emotional well-being (Haddix et al. 

2003). As with smoking-attributable increases in morbidity and premature mortality, the economic costs of 

smoking have been estimated for decades. Since 1991, for 

example, CDC has used the SAMMEC model to estimate 

the economic costs associated with lost productivity due 

to premature death from tobacco use (Shultz et al. 1991; 

USDHHS 2014). These estimates are produced by first 

estimating the total number of years of productive life lost 

from early mortality attributable to smoking and then converting that loss into financial terms to indicate monetary 

loss because of lost work productivity. Using the SAMMEC 

model, CDC estimated, for example, that the average 

annual smoking-attributable economic cost of lost productivity for 2000−2004 was $96.8 billion when premature 

mortality alone was considered (CDC 2008). Combining the 

costs of lost productivity with the direct healthcare expenditures attributable to smoking of $96 billion during the 

same period, the total annual smoking-attributable economic cost was $193 billion (CDC 2008). Using data linked 

between the 2006–2010 Medical Expenditure Panel Survey 

and the 2004–2009 National Health Interview Survey, 

the estimated annual healthcare expenditure attributable to smoking was as much as $170 billion in 2010 dollars; public programs—including Medicare, Medicaid, and 

other federally sponsored programs—accounted for more 

than 60% of this estimate (Xu et al. 2015b). However, these 

estimates underestimate the economic impact of smoking, 

because they do not account for smoking-related disability, smoking-related absenteeism from work, smokingattributable loss of earnings, and morbidity and mortality 

attributable to exposure to secondhand smoke.

Regardless, national estimates that are similar to 

those presented above can be developed for states using 

the methodology underlying inclusive state-specific estimates, such as those for the state of California made 

by Max and colleagues (2016). The authors estimated 

smoking-attributable healthcare costs in California in 

2009 using a series of econometric models, which estimated expenditures for such healthcare categories as 

hospital care, ambulatory care, prescriptions, and home 

health and nursing home care. An econometric model was 

also used to predict lost productivity because of illness, 

particularly how smoking status influenced the number 

of days absent from work. Premature mortality because of 

smoking was estimated using an epidemiologic approach. 

Using these approaches, Max and colleagues (2016) calculated $1.4 billion in lost productivity from illness and 

$6.8 million in lost productivity from premature mortality 

among smokers in California in 2009.

The 2014 Surgeon General’s report used three different approaches, all based on the SAMMEC methodology, to derive updated estimates of smoking-attributable 

direct healthcare expenditures (USDHHS 2014):

1. Using medical service costs from 2009, the estimated aggregated annual healthcare expenditure

attributable to cigarette smoking was $132.5 billion

in 2009 dollars. Using the Medical Care part of

the Consumer Price Index to account for inflation

(available from the U.S. Bureau of Labor Statistics

[2017]), the expenditure in 2017 dollars was

$167.7 billion.

2. Using age- and sex-specific relative risks, the estimated

smoking-attributable direct healthcare spending was
A Report of the Surgeon General

466 Chapter 5

$175.9 billion (in 2013 dollars) and $196.7 billion in 

2017 dollars.

3. Using a two-part regression analysis of Medical 

Expenditure Panel Survey (MEPS) data, the estimated smoking-attributable direct healthcare 

spending was $169.3  billion (in 2010 dollars) and 

$207.2 in 2017 dollars (Xu et al. 2015b).

4. The 2014 Surgeon General’s report also used 

updated lifetables and estimates of the present 

value of future earnings to estimate the smokingattributable economic cost of lost productivity; 

the estimate was $150.7  billion in 2009 dollars 

($190.7  billion in 2017 dollars) (USDHHS 2014). 

Moreover, the report estimated the economic cost 

of lost productivity because of exposure to secondhand smoke to be an additional $5.7 billion in 

2009 dollars ($7.2 billion in 2017 dollars), a figure 

that did not account for direct healthcare expenditures attributable to exposure to secondhand smoke 

(USDHHS 2014). The value of lost productivity 

attributable to premature death from smoking was 

$172.2 billion in 2009 ($217.9 billion in 2017 dollars), and the cost attributable to exposure to secondhand smoke was $6.5 billion in 2009 ($8.2 billion in 2017 dollars).

On the basis of these updated estimates, the 2014 

Surgeon General’s report concluded that the costs of cigarette smoking represented a significant portion (7.6–

8.7%) of healthcare expenditures in the United States 

(USDHHS 2014).

The SAMMEC model uses a cross-sectional approach 

to determine the economic expenditures of smoking; it 

estimates the burden of smoking-related disease and death 

of smokers compared with having a population of all nonsmokers and calculates the disease-attributable smoking 

expenditures within a specific period. Another method for 

evaluating the overall economic costs of smoking is the 

life-cycle approach, which estimates the present value of 

the cost of adding a smoker to society and also considers 

that benefits from longer lives because of smoking cessation or prevention will be mitigated because of other 

costs later in life. The life-cycle approach has been implemented using various datasets from national panels in the 

United States.

Sloan and colleagues (2004) used a life-cycle 

approach to estimate the overall cost of smoking. They 

incorporated private costs to smokers, including disability 

and absenteeism; external costs to society, including 

Social Security benefits, pensions, and life insurance; 

and quasi-external costs to family members because of 

their exposure to secondhand smoke. The authors estimated that each new cohort of U.S. smokers, beginning at 

24 years of age, added $203.8 billion of new lifetime costs 

(in year 2000 dollars). Most of the lifetime costs to society 

were private ($168.5  billion), but external and quasiexternal costs (costs imposed by smoking on the spouse 

and children of a smoker) (total of $35.3 billion) were substantial, even after accounting for federal and state tobacco 

excise taxes at the time of estimation. These external and 

quasi-external costs are much higher than previous estimates of externalities from cigarette smoking, primarily 

because of a better understanding of health effects from 

exposure to secondhand smoke (Chaloupka and Warner 

2000; Sloan et al. 2004). Although these estimates suggest 

that a rational decision maker would never choose to initiate tobacco use, individual decision making may highly 

discount future negative events for perceived current 

effects and may be further affected by the limited information on risk considered by potential smokers (Gruber and 

Koszegi 2001; Gruber 2002).

Regardless of underlying methodology, these estimates document the substantial costs associated with 

smoking. However, these macro-level costs hide the significant costs incurred by the households of smokers, 

which include not only the costs of purchasing tobacco 

products but also economic losses because of absenteeism 

from work—because of smoking-related morbidity—and 

of the direct costs of healthcare. Such household costs are 

differentially distributed in the United States, given the 

strong gradient of less smoking with increasing income 

(CDC 2011). Furthermore, the estimated total costs 

include only direct costs and productivity losses; these 

estimates do not consider harder-to-quantify and intangible costs, such as those from the grief and suffering of 

family members and friends of ill smokers. Those costs 

can be measured through surveys using a “willingness-topay” approach, which asks how much a person would pay 

to avoid such a scenario. Costs estimated through willingness-to-pay approaches are often much larger than costs 

that are measured directly (Gold et al. 1996).

Economics of Smoking Cessation

An economic analysis of smoking cessation must 

consider a variety of costs, including costs accrued by 

smokers before successful cessation. Although many persons can quit smoking without any assistance, others need 

assistance from public health programs that encourage 

smoking cessation, or from healthcare services that provide psychological or pharmacologic assistance to help 

them stop smoking. These interventions, which increase 

smoking cessation, also have associated costs.
The Benefits of Smoking Cessation on Overall Morbidity, Mortality, and Economic Costs 467

Smoking Cessation

Principles of Cost-Benefit and Cost-Effectiveness 

Analysis

Policies to encourage beneficial behaviors are often 

evaluated by cost-benefit analysis, which compares outcomes in terms of dollar value and prioritizes different policies, particularly when resources are scarce or funds are 

limited (Russell 2015). The simplest method for comparison 

is to derive a single estimate for each policy by converting 

all costs and benefits into financial measures. In healthcare, 

however, the full benefits associated with improved health 

are not easily converted into financial benefits because of 

challenges in the financial valuations of extending life or 

avoiding morbidity (Gold et  al. 1996). As a result, costeffectiveness analysis is often used in healthcare, but the 

measurements of effect may not always be comparable across 

studies. One type of cost-effectiveness analysis is cost-utility 

analysis, in which health benefits are based on a common 

metric, such as quality-adjusted life-years (QALYs) gained 

(Gold et al. 1996). Recommendations on cost-effectiveness 

in health and medicine were published in 1996 (Gold et al. 

1996; Russell et al. 1996; Siegel et al. 1996; Weinstein et al. 

1996) and updated in 2016 (Sanders et al. 2016).

The particular analytic perspective to choose and 

the evaluation of ratios are two key considerations for 

both cost-benefit and cost-effectiveness analyses. The analytic perspective taken can change the costs and benefits 

of an evaluation, because evaluations using one perspective (e.g., that of a payer) may not include the same costs 

or benefits as those using another perspective (e.g., that 

of society in general). For example, if an insurance plan 

accrues the costs of paying for a smoking cessation program but does not reap the benefits from cessation 

because persons frequently switch insurance plans, such 

switching may result in a less cost-effective scenario for 

the plan. From a societal perspective, however, benefits are 

accrued from all persons who quit successfully, regardless 

of switches in insurance plans. Gold and colleagues (1996) 

recommended the societal perspective as the appropriate 

analytic perspective to provide a full accounting of costs 

and benefits, but other perspectives, such as that of the 

payer when a program to promote smoking cessation is 

implemented, may be the focus of an analysis. Sanders and 

colleagues (2016) recommended considering components 

of cost from an analytical perspective (e.g.,  from health 

sector and societal perspectives).

To assess the cost-effectiveness of an intervention, the 

incremental cost-effectiveness ratio is calculated and evaluated. The ratio estimates how much extra cost is needed 

for an intervention compared with alternatives (control 

or next best alternative in terms of effectiveness) to derive 

an extra unit of benefit (e.g., QALY). To compare the relative value of multiple policy interventions, both absolute 

cost-effectiveness ratio (the ratio of the cost of intervention 

minus costs averted by the intervention, divided by QALYs 

gained, where the comparison is between an intervention and a “do nothing” or control) and incremental 

cost-effectiveness ratio (the ratio of costs of interventions 

minus costs averted by the intervention, divided by QALYs 

gained, where the comparison is between an intervention 

and the next best intervention) can be estimated (Cohen 

and Reynolds 2008). When evaluating one intervention 

versus a control, the absolute cost-effectiveness and incremental cost-effectiveness are the same. However, an evaluation of multiple interventions should be based on incremental cost-effectiveness ratios. Relying only on absolute 

cost-effectiveness ratios can distort estimates and result in 

invalid conclusions. The absolute cost-effectiveness ratios 

of alternative interventions can be similar and cost-effective 

when compared with an acceptable threshold. However, 

when the incremental cost-effectiveness ratio for an alternative is evaluated and compared with the next best alternative, the alternative may not necessarily be cost-effective—

even if it is cost-effective when compared with the control.

An international consortium that evaluated the relative costs and benefits of a range of smoking cessation interventions found that in a high-income country, such as the 

United States, such interventions as automated text messaging, self-help materials, and brief advice from a physician 

have a low cost but only small effects on smoking cessation. 

Conversely, pharmacological and psychological interventions (either by telephone or provided in person) are higher 

in cost but have greater effects on increasing smoking cessation (West et al. 2015). In another examination of relative 

costs and benefits that used a much different framework 

to gauge benefit, disability-adjusted life-years gained, Jha 

and colleagues (2006) found that NRT may be more costeffective than other interventions—its higher price notwithstanding. A systematic review on the economic impact 

of a conservative 20% price increase of tobacco products 

through taxation found evidence of per capita cost savings 

over the short- and medium terms (Contreary et al. 2015).

Because of their relatively high cost, pharmacologic and psychologic smoking cessation interventions 

have been more closely evaluated than inexpensive interventions. This report summarizes the cost-effectiveness 

ratios gleaned from the review of literature on the costeffectiveness of clinical cessation interventions and compares the estimates to a threshold of cost-effectiveness for 

clinical interventions used in healthcare (Neumann et al. 

2014; Sanders et al. 2016).

Cost-Effectiveness of Clinical Smoking Cessation 

Interventions

In a systematic review of the literature, Ruger 

and Lazar (2012) summarized the evidence on the costeffectiveness of smoking cessation through 2009. This 
A Report of the Surgeon General

468 Chapter 5

review covered literature indexed in PubMed and the British 

National Health Service’s Economic Evaluation Database 

as containing an economic evaluation (cost-benefit, costeffectiveness, cost-utility, or cost-minimization analysis) 

of pharmacotherapy or counseling for smoking cessation. The review examined 36  economic evaluations in 

detail, including 14  studies of NRT, 12  studies of nonnicotine-based pharmacotherapy, and 10 studies of brief 

counseling for smoking cessation. The review found that 

cost-effectiveness and other types of economic evaluation 

studies do not routinely use standard metrics to evaluate 

benefits and often use the payer’s perspective, not the 

societal perspective as recommended (Tables 5.6–5.8). 

To standardize dollar value of costs to the same base year, 

estimates in this section were converted to 2017 U.S. dollars from the base case year (or publication year if the 

base case year was not known) using the Medical Care 

part of the Consumer Price Index (all urban consumers). 

When performing benefit-cost analyses, USDHHS typically values QALY gains at about $500,000  or $850,000, 

depending on the discount rate applied (USDHHS 2016). 

This is substantially larger than the recently recommended values of $100,000 or $150,000 per QALY gained 

(Neumann et al. 2014).

Table 5.6 summarizes studies on nicotine-based 

pharmacotherapies. For NRT, RCTs in the United Kingdom 

estimated that when NRT was added to brief counseling in 

primary care settings, incremental cost per life-year saved 

ranged from $1,115 to $2,541 depending on the age groups 

from the national health system perspective (Stapleton 

et  al. 1999). According to two more recent studies, the 

cost of NRT per additional quitter was $171 compared with 

usual care from the health insurance perspective (Salize 

et  al. 2009) and was $3,781  compared with brief counseling from the state program perspective (Hollis et  al. 

2007). In an examination of observational data, adding free 

NRT to quitline counseling in the United States resulted in 

incremental costs of $132 per life-year saved and $267 per 

quit attempt in Oregon from the program perspective 

(Fellows et  al. 2007) and of $808  per quit attempt in 

Minnesota from the funding agency perspective (An et al. 

2006). Three studies that used decision-analytic modeling 

found incremental cost-effectiveness ratios ranging from 

$9,463  to $23,589  per QALY gained for physician-based 

cessation counseling with nicotine patch compared with 

counseling alone from the payer perspective (Fiscella and 

Franks 1996), $2,388 to $9,791 per QALY gained from the 

societal perspective (Cromwell et al. 1997), and $2,511 to 

$6,020 per life-year saved for NRT compared with counseling or advice alone from the national health services 

perspective (Song et al. 2002).

Five studies that modeled populations of smokers estimated incremental cost-effectiveness ratios for counseling 

and NRT compared with brief physician counseling alone 

ranged from $1,267  to $42,160  per life-year saved from 

the payer perspective (Oster et al. 1986; Wasley et al. 1997; 

Gilbert et al. 2004; Cornuz et al. 2006) and from $2,021 to 

$9,002  per QALY gained from the societal perspective 

(Feenstra et al. 2005). Among two studies on pharmacistdirected smoking cessation programs, one involving only 

the receipt of advice and motivation compared with usual 

advice from a pharmacist found cost-effectiveness ratios 

ranging from $628  to $2,678  per life-year saved from 

the payer perspective (Crealey et al. 1998), and the other 

incorporating four methods under pharmacist direction 

(quitting cold turkey, two kinds of NRT, and bupropion) 

compared with self-directed quit attempts found costeffectiveness ratios ranging from $478 to $2,496 per successful quit from the payer perspective (Tran et al. 2002).

Table 5.7 summarizes cost-effectiveness studies of 

non-nicotine-based pharmacotherapies. Five studies evaluated varenicline and compared it with different comparators (nortryptiline; bupropion, NRT, and unaided cessation; 

brief counseling alone and unaided cessation; counseling; 

or NRT). Incremental cost-effectiveness ratios ranged from 

$1,409  to $5,838  per quit attempt from the healthcare 

system perspective (Hoogendoorn et  al. 2008) and from 

dominates (i.e., less costly and more effective) to $4,981 per 

QALY gained from the healthcare payer/system perspective 

(Hoogendoorn et al. 2008; Howard et al. 2008; Annemans 

et al. 2009; Bolin et al. 2009b; Igarashi et al. 2009). In some 

trials, varenicline was more efficacious than the comparison strategy (whether unaided cessation or cessation 

with NRT or bupropion) and more cost-effective from various perspectives (healthcare payer/system) (Howard et al. 

2008; Annemans et al. 2009; Bolin et al. 2009b; Igarashi 

et al. 2009). Two other studies also showed that an extended 

period of varenicline treatment compared with placebo or 

12 weeks of varenicline, bupropion, or NRT was less costly 

and more effective per QALY gained from the healthcare 

perspective (Knight et  al. 2010) and was more effective 

than placebo, with incremental cost-effectiveness ratios as 

high as $41,053 per QALY gained from the societal perspective (Bolin et al. 2009a). Studies comparing bupropion with 

NRT found incremental cost-effectiveness ratios as high 

as $1,223  per QALY gained from the societal perspective 

(Bolin et  al. 2006). One study compared bupropion with 

counseling or advice alone and found that the incremental 

cost per life-year saved ranged from $1,603 to $3,746 from 

a national health system perspective (Song et al. 2002).

Table 5.8 summarizes 10  studies that evaluated 

brief counseling therapies conducted with a variety of 

methods, in diverse settings, and with diverse populations. Using data from RCTs, an evaluation of care that 

included 20  minutes of bedside counseling, 12  minutes 

of videos, self-help materials, and follow-up calls found 
Study Design/population Effects Costs Outcomes/findings

Oster et al.

(1986)

•

•

•

•

–

–

•

•

Meta-analysis

Cost-effectiveness analysis

Hypothetical group of smokers seen in 

routine office visits

Intervention/comparison:

Physician advice and counseling alone

Nicotine gum and physician advice

Perspective: Payer

Lifetime

• Life-years saved •

•

•

Physician time and gum

Base year: 1984

Source: Retail prices, 

salary rates

•

•

•

Range of cost per life-year saved, by sex:

Men: $4,113–$6,465 ($18,305–$28,773 in

2017 $)

Women: $6,880–$9,473 ($30,620–$42,160

in 2017 $)

Fiscella and

Franks (1996)

• Decision analytic model

• Cost-effectiveness and cost-utility analyses

• Male and female smokers, 25–69 years of

age receiving primary care

• Intervention/comparison:

– Physician-based smoking cessation 

counseling with nicotine patch

– Physician-based smoking cessation 

counseling alone

• Perspective: Payer

• Lifetime

• QALYs saved • Physician time and retail

price of nicotine patch

• Base year: 1995

• Source: Published average

wholesale price

• The nicotine patch produced one additional 

lifetime quitter at a cost of $7,332 ($15,805 

in 2017 $)

• Range of incremental cost-effectiveness of 

the nicotine patch, by sex:

• Men: $4,390–$10,943 per QALY

($9,463–$23,589 per QALY in 2017 $)

• Women: $4,955–$6,983 per QALY

($10,681–$15,053 per QALY in 2017 $)

Cromwell et al.

(1997)

•

•

•

• I

i

•

•

Decision probabilities model

Cost-effectiveness analysis of clinical practice

guidelines and cost-utility analysis

Simulated model of U.S. smokers, 18 years 

of age or older who were willing to make a

quit attempt within 1 year

ntervention/comparison: Model of five 

counseling interventions for primary care 

physicians (minimal, brief, and full) and 

specialists (individual intensive and group 

ntensive) with and without transdermal 

nicotine and nicotine gum

Perspective: Societal

1 year

•

•

QALYs and lifeyears saved

Quit rates

•

•

•

Implementation of

guidelines (screening, 

advice, motivational 

sessions, and interventions)

Base year: 1995

Source: Published literature,

guideline reports, and

Medicare charges

•

•

•

Implementing the guidelines cost $3,779

($8,146 in 2017 $) per quitter, $2,587 ($5,577 

in 2017 $) per life-year saved, and $1,915

($4,128 in 2017 $) per QALY saved

Costs per QALY ranged from $1,108 to $4,542

($2,388 to $9,791 in 2017 $)

More intensive interventions were more costeffective than those with less intensity

Table 5.6 Summary of economic evaluations of nicotine-based pharmacotherapies for smoking cessation

The Benefits of Smoking Cessation on Overall Morbidity, Mortality, and Economic Costs 469
Study Design/population Effects Costs Outcomes/findings

Wasley et al.

(1997)

• Meta-analysis

• Cost-effectiveness analysis

• Hypothetical samples of 400 smokers 

who smoke ≥20 cigarettes per day

• Intervention/comparison:

• Nicotine patch with brief counseling

• Brief physician counseling alone

• Perspective: Payer

• Lifetime

• Life-years saved

• Quit rates

• Physician time and 

nicotine patch

• Base year: 1995

• Source: Average retail 

cost and physicians’ 

medical fee schedules

• Range of average cost per life-year saved, 

by sex:

• Men: $965–$1,585 ($2,080–$3,417 in 

2017 $)

• Women: $1,634–$2,360 ($3,522–$5,087 

in 2017 $)

• Range of incremental cost per life-year saved, 

by sex:

• Men: $1,796–$2,949 ($3,872–$6,357 in 

2017 $)

• Women: $3,040–$4,391 ($5,553–$9,379 

in 2017 $)

Crealey et al. 

(1998)

•

•

•

•

•

•

•

•

Case control

Cost-effectiveness analysis

Matched cases (52) and controls (60) in 

PAS model program in Northern Ireland

Intervention/comparison:

Cases received advice and motivation 

to quit from pharmacist

Matched controls received usual advice 

from pharmacists

Perspective: Payer

Lifetime

•

•

•

Range of cost for PAS program per life-year 

saved, by sex:

Men: $337–$603 ($683–$1,222 in 2017 $)

Women: $310–$1,322 ($628–$2,678 in 

2017 $)

Stapleton et al. 

(1999)

• Randomized controlled trial and survey

• Cost-effectiveness analysis

• 1,200 patients who smoked ≥15 cigarettes 

per day in 15 English counties

• Intervention/comparison:

• Brief counseling with general practitioner 

plus 16-hour nicotine patch treatment 

and booklet

• Brief counseling with general practitioner 

survey plus placebo and booklet

• Perspective: National Health Service

• 12 weeks

• Life-years saved • Treatment (counseling 

time, nicotine patches, 

patient booklets, and 

biochemical validation 

of abstinence)

• Base year: 1998

• Source: National survey 

data and resource use

• Incremental cost per life-year saved among 

patients if practitioners could prescribe 

nicotine patch, by age group:

45–54 years: $712 ($1,398 in 2017 $)

• <35 years: $656 ($1,288 in 2017 $)

• 35–44 years: $568 ($1,115 in 2017 $)

•

• 55–65 years: $1,294 ($2,541 in 2017 $)

•

•

•

Direct intervention

(PAS materials, training 

for pharmacists, and 

time spent counseling) 

Base year: 1997 

Source: Estimates of 

program costs and 

salary rates 

• Life-years saved

Table 5.6 Continued

A Report of the Surgeon General

470 Chapter 5
Study Design/population Effects Costs Outcomes/findings

Tran et al.

(2002)

•

•

•

•

•

•

•

•

Observations

Cost-effectiveness and cost-utility analyses

48 patients 21–70 years of age who had tried 

at least once to quit smoking

Intervention/comparison:

Pharmacist-directed smoking cessation 

program using four methods (cold turkey, 

nicotine patch, nicotine gum, bupropion)

Self-directed quit attempt

Perspective: Payer and societal

1 year, lifetime

•

•

•

Quit rate

Life-years saved

QALYs saved

•

•

•

•

Materials and

pharmacist time

Selected cessation

methods (retail cost)

Base year: 1997

Source: Salary data

and retail costs

• Incremental costs (in 2017 $) using 

pharmacist-directed program, by method 

of smoking cessation per successful quit 

from the payer perspective:

–

–

–

–

$236 ($478 in 2017 $) for cold turkey

$936 ($1,896 in 2017 $) for nicotine patch

$1,232 ($2,496 in 2017 $) for nicotine gum

$1,150 ($2,370 in 2017 $) for bupropion

Gilbert et al.

(2004)

• Markov chain cohort simulation

• Cost-effectiveness analysis

• Two simulated cohorts of smokers in 

Seychelles (Africa)

• Intervention/comparison:

• Physician counseling alone

• Counseling plus one of five cessation 

therapies (nicotine gum, patch, spray,

inhaler, or bupropion)

• Perspective: Third-party payer

• Lifetime

• Life-years saved • Additional physician

time required

• Treatment (retail prices

for generic treatment

medications)

• Base year: 2002–2003

• Source: Retail prices

and wage data

• Incremental cost per life-year saved, by type 

of therapy (U.S. prices):

– $3,712 ($5,939 in 2017 $) for nicotine gum

– $1,982 ($3,171 in 2017 $) for nicotine patch

– $4,597 ($7,355 in 2017 $) for nicotine spray

– $4,291 ($6,865 in 2017 $) for nicotine 

inhaler

– $1,324 ($2,118 in 2017 $) for bupropion

Feenstra et al.

(2005)

•

•

•

•

RIVM chronic disease

Cost-effectiveness and cost-utility analyses

Smokers in the Netherlands

Intervention/comparison:

–

–

–

Minimal counseling by a general 

practitioner with or without NRT

Intensive counseling by a general 

practitioner with NRT or bupropion

Telephone counseling

•

•

Perspective: Societal

1, 10, or 75 years

•

•

•

Quit rate

Life-years gained

QALYs gained 

•

•

•

•

Intervention

Healthcare for11smokingrelated diseases (direct

costs only)

Base year: 2000

Source: Estimated retail 

costs, standard costing

manual, and salary data

• Cost per QALY gained ranged from $1,109 

($2,021 in 2017 $) for telephone counseling 

to $4,939 ($9,002 in 2017 $) for intensive 

counseling with nicotine patches or gum

Table 5.6 Continued

The Benefits of Smoking Cessation on Overall Morbidity, Mortality, and Economic Costs 471
Study Design/population Effects Costs Outcomes/findings

An et al. (2006) • Before and after initiative 

• Cost-effectiveness analysis 

• 373 callers to the MinnesotaQUITPLAN 

helpline 

• Intervention/comparison: 

– Quitline callers before initiative 

– Quitline callers enrolled in multisession

counseling receivedNRT (patch or gum)

by mail 

• Perspective: Funding agency 

• 6 months 

• Quit rate • Counseling and provision 

of free NRT

• Base year: Not available

• Source: Estimated 

program costs

• Average number of ex-smokers per month 

increased from 16 to 124

• Average cost per quit increased from $1,362 

($1,926 in 2017 $) to $1,934 ($2,734 in 2017 $)

Cornuz et al. 

(2006)

•

•

•

•

–

 

–

•

•

Markov-chain cohort simulation 

Cost-effectiveness analysis 

Simulated cohorts of smokers in six countries 

(Canada, France, Spain, Switzerland, United 

States, and United Kingdom) 

Intervention/comparison: 

Brief cessation counseling by 

general practitioner 

Counseling plus NRT 

Perspective: Third-party payer 

Lifetime 

• Life-years saved •

•

•

Additional physician time 

required plus medications 

(retail price)

Base year: 2002–2003

Source: Pharmacy prices 

and published price data 

from each country

• Range of cost per life-year saved, by type of 

therapy and sex:

–

–

–

–

–

Gum:





















$2,230 for men ($3,568 in 2017 $)

$7,643 for women ($12,228 in 2017 $)

Patch:

$1,758 for men ($2,813 in 2017 $)

$5,131 for women ($8,209 in 2017 $)

Spray:

$1,935 for men ($3,096 in 2017 $)

$7,969 for women ($12,749 in 2017 $)

Inhaler:

$3,480 for men ($5,568 in 2017 $)

$8,700 for women ($13,919 in 2017 $)

Bupropion:

$792 for men ($1,267 in 2017 $)

$2,922 for women ($4,675 in 2017 $)

Fellows et al.

(2007)

• Before and after free-patch initiative 

• Cost-effectiveness analysis 

• 959 smokers who registered for quitline 

service inOregon 

• Intervention/comparison: 

– Pre-initiative program 

– Free-patch initiative from the Oregon 

tobacco quitline 

• Perspective: Program 

• 1 year 

• Quit rate

• Life-years saved

• Media and intervention 

(before and after the 

initiative)

• Base year: 2004

• Source: Quitline utilization 

and cost data from state, 

intervention providers,

and patients

• Compared with the program before the freepatch initiative, the new initiative increased 

quitting fourfold and reduced total costs per 

quit by $2,688 ($4,120 in 2017 $)

• Free-patch initiative cost $86 ($22–$353) 

($132 [$34–$541] in 2017 $) per life-year 

saved and $174 ($267 in 2017 $) per 

additional quit attempt

Table 5.6 Continued

A Report of the Surgeon General

472 Chapter 5
Study Design/population Effects Costs Outcomes/findings

Hollis et al. 

(2007)

•

•

•

•

•

•

Randomized trial

Cost-effectiveness analysis

4,614 callers to the Oregon tobacco quitline 

who smoked ≥5 cigarettes per day

Intervention/comparison: Brief, moderate, 

and intensive telephone counseling with 

or without offers of free nicotine patches

Perspective: State program

1 year

• Abstinence rate •

•

•

Interventions

Base year: 2004

Source: Program records 

of resources consumed

• Compared with brief counseling with no 

NRT, the added costs for each additional 

quit were:

–

–

–

–

–

$2,467 ($3,781 in 2017 $) for brief 

counseling plus NRT

$1,912 ($2,931 in 2017 $) for moderate 

counseling and no NRT

$2,109 ($3,233 in 2017 $) for moderate 

counseling plus NRT

$2,640 ($4,047 in 2017 $) for intensive 

counseling and no NRT

$2,112 ($3,237 in 2017 $) for intensive 

counseling plus NRT

Salize et al. 

(2009)

• Cluster randomized trial 

• Cost-effectiveness analysis 

• 577 patientswho smoked ≥10 cigarettes per 

day inGermany 

• Intervention/comparison: 

– Training of general practitioners plus

remuneration for each abstinent patient 

– Training of general practitioners plus cost-

 freeNRTand/or bupropion hydrochloride 

– Acombination of both strategies 

• Perspective:Health insurance 

• 1 year 

• Abstinence rate • Interventions

• Base year: 2003

• Source: Unit costs per each 

element of treatment in 

the trial

• Compared with usual care, both training of 

general practitioners plus drugs and training 

of general practitioners plus drugs and 

remuneration were cost-effective

• The cost per additional quitter was $107 

($171 in 2017 $) per patient for training of 

general practitioners plus drugs and $97 

($155 in 2017 $) per patient for training

of general practitioners plus drugs and 

remuneration

Table 5.6 Continued

The Benefits of Smoking Cessation on Overall Morbidity, Mortality, and Economic Costs 473

Source: Table 4 in Ruger and Lazar (2012).

Notes: NRT = nicotine replacement therapy; PAS = pharmacists action on smoking; QALYs = quality-adjusted life-years; RIVM = chronic disease model developed at the 

National Institute of Public Health and the Environment in The Netherlands. Estimates converted to 2017 U.S. dollars from the base case year (or publication year if no 

base case year) using the Medical Care part of the Consumer Price Index (all urban consumers).
Study Design/population Effects Costs Outcomes/findings

Song et al.

(2002)

• Decision analytic model 

• Cost-effectiveness analysis 

• Simulation based on results from 

published studies 

• Intervention/comparison: 

– Advice or counseling alone 

– Advice or counseling plusNRTor 

bupropion sustained release 

– Advice or counseling plusNRTand 

bupropion sustained release 

• Perspective:United Kingdom 

National Health Services 

• 1 year 

•

•

Quit rates

Life-years saved

•

•

•

Intervention

Base year: 2001

Source: Published studies

• Range of incremental cost per life-year saved

compared with counseling or advice alone,

by type of intervention:

–

–

–

$1,441–$3,455 ($2,511–$6,020 in 2017 $)

for NRT

$920–$2,150 ($1,603–$3,746 in 2017 $)

for bupropion sustained release

$1,282–$2,836 ($2,234–$4,941 in 2017 $)

for NRT plus bupropion sustained release

Antoñanzas and 

Portillo (2003)

• Adaptation of health and economic 

consequences of smoking interactive 

simulation

• Cost-effectiveness analysis

• Smokers in Spain

• Intervention/comparison:

– Bupropion

– NRT (nicotine patch or gum)

• Perspective: National health system

• 20 years

• Deaths prevented

• Life-years saved

• Intervention

• Healthcare costs for 

tobacco-related diseases 

or conditions (cancers, 

CHD, stroke, COPD, and 

low birth weight)

• Base year: 1999

• Source: National Health 

Survey and National 

Institute of Statistics

• At 20 years, for bupropion and the nicotine 

patch, respectively, there was a net savings 

of $32,920 ($62,441 in 2017 $) and $15,993 

($30,334 in 2017 $) per death prevented 

and a net savings of $3,852 ($7,306 in 

2017 $) and $1,867 ($3,541 in 2017 $)

per life-year saved

• At 20 years, nicotine gum had a costeffectiveness ratio of $41,325 ($78,402 in 

2017 $) per death prevented and $4,786 

($9,078 in 2017 $) per life-year saved

Bolin et al. 

(2006)

•

•

•

•

•

•

Global health outcomes simulation model

Cost-effectiveness analysis

Model cohort of male and female smokers 

in Sweden

Intervention/comparison:

– Bupropion

– NRT (nicotine patches and gum)

Perspective: Societal

20 years

• QALYs gained •

•

•

•

•

Intervention 

Direct costs of smoking 

(COPD, asthma, CHD, 

stroke, and lung cancer) 

Reduced production and 

consumption (indirect 

costs of smoking) 

Base year: 2001 

Source: Swedish unit 

costs, hospital records, 

and physician records 

• When direct and indirect costs on production 

and consumption were included, bupropion 

was cost-saving compared with both types

of NRT

• When only direct costs were included, 

incremental cost per QALY gained for 

bupropion compared with nicotine patches 

was $702 ($1,223 in 2017 $) for men and

$521 ($908 in 2017 $) for women

Table 5.7 Summary of economic evaluations of non-nicotine-based pharmacotherapies for smoking cessation

A Report of the Surgeon General

474 Chapter 5
Study Design/population Effects Costs Outcomes/findings

Halpern et al. 

(2007)

•

•

•

•

–

–

–

–

•

•

Decision analytic model 

Cost-effectiveness analysis 

Simulation in cohort of 1,000 smokers 

in theUnited States 

Intervention/comparison: 

Varenicline (12 weeks) 

Nicotine patch (9 weeks) 

Bupropion (12 weeks) 

No intervention 

Perspective: Private health plans, state 

Medicaid program, and employer 

10 years 

• Abstinence rates • Intervention

• Medical care for 

smoking-related 

diseases (CHD, COPD, 

and lung cancer) and 

pregnancy complications

• Productivity losses and 

absenteeism

• Base year: 2005

• Source: Literature 

• Compared with unaided cessation, costeffectiveness of varenicline per additional

cessation at 2 years ranged from $648

($953 in 2017 $) in the private health plan

model to $1,229 ($1,049 in 2017 $) in the

Medicaid model

Hoogendoorn

et al. (2008)

• BENESCO model

• Cost-effectiveness and cost-utility analyses

• Hypothetical cohort of Dutch smokers

making a one-time quit attempt

• Intervention/comparison:

– Varenicline

– Untreated or treated with bupropion,

nortriptyline, or NRT

• Perspective: Dutch healthcare system

• Lifetime

• Quit rate

• QALYs gained

•

•

•

•

Intervention

Direct medical costs of 

smoking-related diseases 

(COPD, lung cancer, CHD, 

and stroke)

Base year: 2004

Source: Estimates from

Dutch source data 

•

•

Varenicline estimated to cost $1,472 ($2,256

in 2017 $) per QALY gained compared with

nortriptyline and $285 ($437 in 2017 $)

per QALY gained compared with unaided

cessation

Cost of varenicline per additional quitter

ranged from $919 ($1,409 in 2017 $)

compared with NRT to $3,809 ($5,838 in

2017 $) compared with nortriptyline

Jackson et al.

(2007)

• Decision tree model

• Cost-benefit analysis

• Simulation based on published results

of clinical trial

• Intervention/comparison:

– Varenicline

– Bupropion (brand and generic)

– Placebo

• Perspective: Employer

• 1 year

• Quit rates • Intervention

• Cost of smoking for

employer (absenteeism,

medical care, time lost,

and insurance)

• Base year: 2006

• Source: Study detailing

direct and indirect costs of

smoker to an employer, and

pricing related to wholesale 

acquisition costs

• Cost savings per nonsmoking employee at 

1 year, by type ofintervention: 

– $541 ($765 in 2017 $) for varenicline 

– $270 ($382 in 2017 $) for bupropion 

sustained release (generic) 

– $151 ($213 in 2017 $) for bupropion 

sustained release (brand) 

– $82 ($116 in 2017 $) for placebo 

Table 5.7 Continued

The Benefits of Smoking Cessation on Overall Morbidity, Mortality, and Economic Costs 475
Study Design/population Effects Costs Outcomes/findings

Howard et al. 

(2008)

•

•

•

BENESCO Markov simulation

Cost-utility analysis

Hypothetical cohort of U.S. adult smokers 

who make a one-time quit attempt

–

–

–

–

–

Intervention/comparison:

Varenicline

Bupropion

NRT

Unaided quitting

•

•

Perspective: U.S. healthcare system

20 years and lifetime

• QALYs •

•

•

Intervention

Directlifetime costs of 

smoking-related 

diseases (lung cancer, 

COPD, CHD, stroke, and 

asthma)

Base year: 2005 

• Varenicline was less costly and more effective 

(dominates) than other cessation strategies 

(bupropion, NRT, and unaided cessation) 

over either time period studied (20 years 

and lifetime) 

Annemans et al.

(2009)

• BENESCO Markov simulation

• Cost-effectiveness and cost-utility analyses

• Cohort of Belgian adult smokers making 

a one-time quit attempt

• Intervention/comparison:

– Varenicline, bupropion, or NRT with 

brief counseling

– Brief counseling alone

– Unaided cessation

• Perspective: Healthcare payer (public

• and private)

• Lifetime

• Life-years gained

• QALYs gained

• Intervention

• Direct medical costs related 

to smoking comorbidities 

(COPD, lung cancer, CHD, 

stroke, and asthma)

• Base year: 2007

• Source: Literature and 

public health databases 

• Compared with brief counseling alone and

unaided cessation, varenicline cost $337 

($456 in 2017 $) per life-year gained and

$2,325 ($3,148 in 2017 $) per QALY gained

• Varenicline is cost-saving compared with 

bupropion and NRT

Bolin et al. 

(2009a)

•

•

•

•

•

BENESCO Markov simulation

Cost-utility analysis

Simulated cohort of adult smokers in Sweden 

who successfully abstained after an initial

12-week treatment of varenicline

Intervention/comparison:

–

–

Additional 12 weeks of varenicline

Placebo

•

•

Perspective: Societal

50 years

• QALYs gained •

•

•

•

•

Intervention

Average direct medical 

costs from smoking-related 

diseases (COPD, CHD, 

stroke, and lung cancer)

Average value ofindirect 

effects (reduced consumption 

and production)

Base year: 2003

Source:Healthcare cost

data from Skåne, Sweden; 

estimated prescription 

prices; and published 

literature

•

•

Incremental costs per QALY for additional 

12 weeks of varenicline compared with 

placebo were $7,420 ($11,871 in 2017 $) 

for men and $7,464 ($11,941 in 2017 $) 

for women

Incremental costs per QALY, including

indirect effects, were $25,359 ($40,571 in 

2017 $) for men and $25,660 ($41,053 in 

2017 $) for women

Table 5.7 Continued

A Report of the Surgeon General

476 Chapter 5
Study Design/population Effects Costs Outcomes/findings

Bolin et al.

(2009b)

• BENESCO Markov simulation 

• Cost-effectiveness and cost-utility analyses 

• Simulated model in four European 

countries (Belgium, France, Sweden, 

andUnitedKingdom) 

• Intervention/comparison: 

– Varenicline 

– NRT 

• Perspective:National healthcare system 

• Lifetime 

• Life-years gained

• QALYs gained

• Intervention

• Morbidity-related

healthcare costs from

four smoking-related

morbidities (lung cancer,

COPD, CHD, and stroke)

• Base year: Not available

• Source: Country-specific

databases

• In a typical smoking cessation intervention,

using varenicline instead of NRT was costsaving in all countries except France, which

had a cost-effectiveness ratio of $3,936

($4,981 in 2017 $) per QALY gained

Igarashi et al.

(2009)

• Markov model 

• Cost-utility analysis 

• Simulated cohort of smokers in Japan 

who started smoking at 20 years of age 

• Intervention/comparison: 

– Counseling on smoking cessation by 

a physician 

– Counseling plus varenicline therapy 

•

•

•

•

Perspective:Healthcare payer 

Lifetime 

• QALYs gained • Treatment

• Direct lifetime medical

costs for tobaccoassociated disease

• Base year: 2007

• Source: Survey of public

health insurance, National

Health Insurance, and

drug tariff

• Adding varenicline to counseling increased

QALYs and saved medical costs among men

Adding varenicline to counseling had an

incremental cost-effectiveness ratio of

$3,010 ($4,075 in 2017 $) per QALY gained

in women

Knight et al.

(2010)

BENESCO Markov simulation

Cost-effectiveness and cost-utility analyses

Hypothetical population of adult American

smokers who made a single quit attempt

• Intervention/comparison:

– Initial 12 weeks plus additional 12 weeks

of varenicline

– 12 weeks of varenicline, bupropion,

NRT, or unaided cessation

• Perspective: Healthcare system

• 5, 10, and 20 years and lifetime

• QALYs gained •

•

Directtreatment

Morbidity-related 

healthcare costs of 

smoking-related 

diseases (lung cancer, 

stroke, CHD, COPD, and 

asthma)

•

•

Base year: 2005

Source: Literature, prices

in 2005U.S.RedBook 

• An additional 12 weeks of varenicline

increased 1-year abstinence rates from 23%

to 28% (compared with initial 12 weeks of 

varenicline)

• During the lifetime of all participants, an

additional 12 weeks of varenicline was costeffective compared with the initial 12 weeks

of varenicline (an incremental cost per QALY

gained of $972 ($1,429 in 2017 $)) and was

less costly and more effective (dominates)

than other alternatives (bupropion, NRT, 

and unaided cessation)

Table 5.7 Continued

The Benefits of Smoking Cessation on Overall Morbidity, Mortality, and Economic Costs 477

Source: Table 5 in Ruger and Lazar (2012).

Notes: BENESCO = benefits of smoking cessation on outcomes; CHD = coronary heart disease; COPD = chronic obstructive pulmonary disease; NRT = nicotine replacement 

therapy; QALYs = quality-adjusted life-years. Estimates converted to 2017 dollars from the base case year (or publication year if no base case year) using the Medical Care part 

of the Consumer Price Index (all urban consumers).
Study Design/population Effects Costs Outcomes/findings

Cummings et al.

(1989)

• Model: Not available

• Cost-effectiveness analysis

• Hypothetical group of patients who were

smokers and were seen during a routine

office visit

• Intervention/comparison: Physician 

counseling patients for 4 minutes during 

a routine office visit to quit smoking

• Perspective: Societal

• Time: Not available

• Quit rates

• Life-years saved

• Physician time spent

counseling

• Self-help materials

• Base year: 1984

• Source: Average cost of 

physician visit ($30) and 

cost of materials ($2)

• Brief advice cost $705–$988 ($3,138–$4,397 

in 2017 $) per life-year saved for men and 

$1,204–$2,058 ($5,358–$9,159 in 2017 $) 

per life-year saved for women

Meenan et al.

(1998)

• Randomized controlled trial

•

•

•

•

•

Cost-effectiveness analysis

Hospitalized adult smokers in two acutecare hospitals in a large group model 

HMO in Oregon and Washington

Intervention/comparison:

– 20-minute bedside counseling session 

with health counselor, 12-minute video, 

self-help materials, and one or two 

follow-up phone calls

– Usual care

Perspective: Implementing hospital

1 year

• Quit rates

• Life-years saved

• Intervention (identify

patients, deliver counseling, 

and follow-up)

• Base year: 1994

• Source: Project surveys, 

expense reports, 

retrospective labor 

estimates, financial staff 

of HMO, and estimates 

from literature

• Cost of intervention was $159 ($358 in 2017 $)

per smoker

• Incremental cost per incremental quit was

$3,697 ($8,382 in 2017 $)

• Incremental cost per incremental discounted 

life-year saved was $1,691–$7,444 ($3,809–

$16,769 in 2017 $)

Haile et al.

(2002)

•

•

•

•

•

•

Cohort

Cost-effectiveness analysis

All smokers attending a noncardiac surgical 

preadmission clinic in Australia

Intervention/comparison: Structured,

interactive computerized smoking 

cessation program

Perspective: Hospital/payer

2 months, 1 year

•

•

Quit rates

Acceptability of 

computerized 

smoking 

cessation 

intervention

•

•

•

Intervention (developing 

program, computer 

hardware, and software)

Base year:Not available 

(study conducted in 1999)

Source: Invoice

• Costs of intervention at 1 year, by smoking

status:

–

–

–

$5.80 ($11.0 in 2017 $) per patient

$24.19 ($45.9 in 2017 $) per smoker

$271.47 ($514.9 in 2017 $) per quitter

Table 5.8 Summary of economic evaluations of brief counseling for smoking cessation

A Report of the Surgeon General

478 Chapter 5
Study Design/population Effects Costs Outcomes/findings

Solberg et al. 

(2006)

•

•

•

•

Model:Not available 

Cost-utility analysis 

Hypothetical group of patients in primary 

care clinics in theUnited States 

Intervention/comparison: 

–

– 

 

–

–

Model 1:One-time counseling 

Model 2: Model 1 plus costs of smokingattributable illness

Model 3: Annual counseling 

Model 4: Model 3 plus costs of smoking-

•

•

attributable illness 

•

•

Perspective: Societal 

Lifetime 

• QALYs • Intervention (clinician 

time, medication, and 

patient time and travel)

• Preventable smokingattributed illness

• Base year: 2000

• Source: Medicare 

reimbursement rates, 

wholesale costs, and 

healthcare charges

• Cost-effectiveness per QALY saved was

$1,100 ($2,005 in 2017 $) for Model 1 and 

2,266 ($4,130 in 2017 $) for Model 3

• Models 2 and 4 were cost-saving, with net 

cost savings of $65 ($118 in 2017 $) and

$542 ($988 in 2017 $), respectively, per 

smoker counseled

Akers et al. (2007)

•

Randomized trial

Cost-effectiveness analysis 

Persons in five northern states (Alaska, 

Idaho,Montana,Oregon, andWashington) 

whowere interestedinquitting smokeless 

tobacco 

•

–

–

I

•

ntervention/comparison: 

Self-help manual only 

Assisted self-help (manual plus videotape

and two supportive phone calls from a

tobacco cessation counselor) 

Perspective: Societal and provider/agency 

18 months 

• Quit rates • Program (materials, 

postage, phone services, 

and counselor and

• staff time)

• Participants’ and 

supporters’ time

• Base year: 2000

• Source: Cost of materials 

in bulk and minimum 

wage in Oregon

• Total cost per participant by perspective and 

type of treatment:

– No treatment:

 Societal: $0 ($0 in 2017 $)

 Provider/agency: $0 ($0 in 2017 $)

– Manual only:

 Societal: $20 ($36 in 2017 $)

 Provider/agency: $8 ($15 in 2017 $)

– Assisted self-help:

 Societal: $56 ($102 in 2017 $)

 Provider/agency: $39 ($71 in 2017 $)

• Incremental cost per quit by perspective and 

type of treatment:

– Manual only:

 Societal: $691 ($1,259 in 2017 $)

 Provider/agency: $481 ($376 in 2017 $)

– Assisted self-help:

 Societal: $1,131 ($2,061 in 2017 $)

 Provider/agency: $973 ($1,773 in 2017 $)

The Benefits of Smoking Cessation on Overall Morbidity, Mortality, and Economic Costs 479

Table 5.8 Continued
Study Design/population Effects Costs Outcomes/findings

Barnett et al.

(2008)

• Randomized trial 

• Cost-effectiveness analysis 

• Mental health outpatients who were smokers 

and being treated for depression 

• Intervention/comparison: 

– Brief contact(stop-smoking guide and

referral list) 

– Stepped smoking cessation program

Perspective:Healthcare payer 

• 18 months 

• Abstinence rates

• Life-years gained

• All smoking cessation

services used by

participants, including

intervention and referral

• Mental healthcare

• Base year: 2003

• Source: Retail cost,

Medicare reimbursement

rates, hospital charge data,

and Red Book prices

• Smoking cessation services cost $6,204

($9,926 in 2017 $) per successful quit or

$5,170 ($8,271 in 2017 $) per life-year gained

• Cessation services plus mental healthcare

cost $11,496 ($18,392 in 2017 $)

per successful quit or $9,580 ($15,327

in 2017 $) per life-year gained

Dino et al.

(2008)

•

•

•

Markov transition model 

Cost-effectiveness analysis 

Students 17–25 years of agewho smoked 

≥5 cigarettes per day and attended selected 

schools inFlorida 

• Intervention/comparison: 

– Not On Tobacco (orN-O-T) smoking 

cessation program 

– Brief, 20-minute intervention 

Perspective: School 

25 years of age 

• Quit rates

• Life-years saved

• Intervention (training,

room and board for trainer,

brochures, and gifts)

• Base year: 2000

• Source: Program and

school records

• Incremental cost-effectiveness ratio for

N-O-T program was $443 ($807 in 2017 $)

per discounted life-year saved in base model:

$1,029 ($1,875 in 2017 $) in worst-case

scenario

$274 ($499 in 2017 $) in best-case

scenario

Ruger et al.

(2008)

•

•

•

•

Randomized controlled trial 

Cost-effectiveness and cost-utility analyses 

• Low-income pregnant women in Boston, 

Massachusetts 

• Intervention/comparison: 

– Motivational interviewing with nurse 

tailored to patient’s stage of readiness 

for cessation 

– Brief counseling 

• Perspective: Societal 

• Lifetime 

• QALYs saved

• Life-years saved

• Program (intervention,

travel, and training)

• Neonatal intensive care

• Maternal healthcare

(cardiovascular and

ng diseases)

• Base year: 1997

• Source: Program records

and published estimates

• For smoking cessation, intervention was

costlier and less effective than usual care

• For relapse prevention, cost-effectiveness of

the intervention was $851 ($1,724 in 2017 $)

per life-year saved and $628 ($1,272 in

2017 $) per QALY saved

Table 5.8 Continued

A Report of the Surgeon General

480 Chapter 5
Study Design/population Effects Costs Outcomes/findings

Thavorn and 

Chaiyakunapr

uk et al. 

(2008)

•

•

•

•

– 

–

Markov model 

Cost-effectiveness analysis 

Two simulated cohorts of Thai smokers— 

40, 50, and 60 years of age—who regularly 

smoked 10–20 cigarettes per day 

Intervention/comparison: 

Structured community pharmacist-based

smoking cessation program (personalized

and supportive advice, assessment,therapy,

self-help material, and follow-up visits) 

Usual care (assessment, brief advice 

and support, and therapy without 

•

•

•

•

•

follow-up care) 

Perspective:Healthcare system 

Lifetime 

• Life-years gained • Intervention (pharmacist 

training, fees, and 

medications)

• Direct medical costs of 

smoking-related diseases 

(COPD, lung cancer, stroke, 

and cardiovascular disease) 

• Base year: 2005 

• Source: Published studies, 

information centers, and 

price index 

• In the cohort of those 40 years of age, 

program resulted in cost savings to the 

health system of $500 ($735 in 2017 $) for 

men and $614 ($903 in 2017 $) for women, 

and 0.18 life-years gained for men and

0.24 life-years gained for women

Boyd and Briggs 

(2009)

Observational study 

Cost-effectiveness and cost-utility analyses 

Smokers who accessed either oftwo 

cessation services between March and 

May 2007 inGlasgow, Scotland 

• Intervention/comparison: 

–

 

–

–

One-to-one cessation supportin

pharmacies 

Group counseling in the community 

Self-quit attempt 

•

•

Perspective:National health system 

4weeks and 1 year 

• Quit rates

• QALYs

• Intervention costs incurred 

by National Health

Service (NRT, professional 

time, overhead, and 

materials used)

• Base year: 2007

• Source: Resource use 

and records from the 

National Health Service

• Incremental cost per additional 4-week 

quitter was $1,512 ($2,047 in 2017 $) for 

pharmacy support and $2,158 ($2,922 

in 2017 $) for group counseling in the 

community compared with self-quit 

cessation attempts

• Incremental cost per QALY gained was

$8,620 ($11,671 in 2017 $) for pharmacy 

services and $10,579 ($14,324 in 2017 $) 

for group counseling in the community 

compared with self-quit cessation attempts

Table 5.8 Continued

The Benefits of Smoking Cessation on Overall Morbidity, Mortality, and Economic Costs 481

Source: Table 6 in Ruger and Lazar (2012).

Notes: COPD = chronic obstructive pulmonary disease; HMO = health maintenance organization; NRT = nicotine replacement therapy; QALYs = quality-adjusted lifeyears. Estimates converted to 2017 dollars from the base case year (or publication year if no base case year) using the Medical Care part of the Consumer Price Index 

(all urban consumers).
A Report of the Surgeon General

482 Chapter 5

that incremental cost-effectiveness ratios ranged from 

$3,809 to $16,769 per life-year saved compared with usual 

care from the implementing hospital perspective (Meenan 

et al. 1998), and another evaluation of stepped cessation 

services found that ratios per life-year gained ranged from 

$8,271 to $15,327 compared with brief contact from the 

healthcare perspective (Barnett et al. 2008). Three evaluations of counseling therapies per additional quit found that 

the incremental cost-effectiveness ratio was $8,382 from 

the implementing hospital perspective (Meenan et  al. 

1998) and that cost-effectiveness ratios ranged from 

$9,926 to $18,392 from the healthcare perspective (Barnett 

et al. 2008) and from $1,259 to $2,061 from the societal 

perspective (Akers et  al. 2007). Using an observational 

design, Boyd and Briggs (2009) found incremental costeffectiveness ratios per QALY gained of $11,671 for one-toone support (by a pharmacist) and $14,324 for group counseling, and found incremental cost-effectiveness ratios per 

quit of $2,047 and $2,922 for one-to-one support and for 

group counseling, respectively, compared with self-quit 

cessation attempts from the national health system perspective. In other studies that compared brief counseling 

or smoking cessation programs with usual care, estimated 

incremental cost-effectiveness ratios ranged from $499 to 

$1,875  per life-year saved from the school perspective 

(Dino et  al. 2008), from $735  to $903  from the healthcare perspective (Thavorn and Chaiyakunapruk 2008), and 

from $3,138 to $9,159 per life-year saved from the societal perspective (Cummings et al. 1989). Additionally, the 

incremental cost-effectiveness ratio was $4,130 per QALY 

gained from the societal perspective (Solberg et al. 2006).

Cost-Effectiveness of Nonclinical Smoking 

Cessation Interventions

Table 5.9 summarizes studies on the cost-effectiveness 

of various policy interventions that promote smoking cessation. To standardize the dollar value of costs to the same 

base year, estimates in this section were converted to 2017 

U.S. dollars from the base case year (or publication year 

if no base case year) using the Medical Care part of the 

Consumer Price Index (all urban consumers). Although 

these studies share this focus, the evaluations were highly 

heterogeneous (Ekpu and Brown 2015). Regardless, some 

of these evaluations estimated cost-effectiveness ratios 

similar to or greater than those for clinical smoking cessation interventions. The estimated incremental costeffectiveness ratios for an NRT program and for a smokefree workplace policy compared with the clinical standard 

were $7,736 and $882 per QALY gained, respectively (Ong 

and Glantz 2005). Villanti and colleagues (2012) evaluated the American Legacy Foundation’s national EX campaign, which was a radio and television campaign from 

2008 designed to promote smoking cessation among adult 

smokers. The estimated incremental cost-effectiveness 

ratios ranged from $47,271 to $102,883 per QALY gained 

from the societal perspective when compared with a hypothetical status quo of no program or change in cessation 

behavior. School-based antitobacco education programs 

compared with status quo have a much wider range of 

estimated incremental cost-effectiveness ratios per QALY 

gained over 50  years, ranging from $9,294  when considering a 56% reduction in smoking that dissipates in 4 years 

to $644,890 when considering a 5% reduction in smoking 

that dissipates in 1 year from the societal perspective. For 

the most plausible scenario of 30%  effectiveness in preventing smoking, which dissipates in 4 years, the estimated 

cost-effectiveness ratio was $37,935 per QALY gained (Tengs 

et al. 2001). In a study evaluating CDC’s Tips From Former 

Smokers (Tips) Campaign among adults, Xu and colleagues 

(2015a) estimated an incremental cost-effectiveness ratio 

of $450 per life-year saved and $307 per QALY gained in the 

short run from the funding agency’s perspective compared 

with not having the campaign.

Cost-Effectiveness of Tobacco Price Increases 

Through Taxation

Contreary and colleagues (2015) conducted a systematic review of the cost-effectiveness of a tobacco price 

increase through taxation and found only one study that 

evaluated the cost-effectiveness per QALY gained. The study 

found that the cost-effectiveness ratio for a 10% increase in 

per unit price of tobacco through a 15% increase in excise 

tax was $3,839 (2017 dollars) per QALY gained over 100 

years from the healthcare perspective (van Baal et al. 2007).

Synthesis of the Evidence

The evidence on cost-effectiveness of smoking cessation and the resulting reduction in healthcare expenditures as a result of cessation strongly indicate that 

smoking cessation interventions should be implemented 

throughout the healthcare system and supported more 

broadly by population-level tobacco control measures 

(e.g., quitlines). The selection of the intervention depends 

on the feasibility of the intervention and on the context of 

an organization and its ability to fund the intervention.

Current estimates of the cost-effectiveness of 

smoking cessation are limited by the variation in methodologies, including heterogeneity in comparators and 

perspectives. Despite specific recommendations made 

two decades ago to enhance the comparability of economic evaluations (Gold et al. 1996), compliance with 

the full set of recommendations on a standard approach 

to conducting cost-effective analysis remains incomplete 

(Ronckers et al. 2005; Ruger and Lazar 2012; Ekpu and 
Study Design/population Effects Costs Outcomes/findings

Tengs et al. 

(2001)

•

•

Tobacco Policy Model (a dynamic simulation 

model)

Intervention/comparison:

–

–

School-based antitobacco education

to seventh- and eighth-grade students, 

with 5–56% smoking reductions that 

dissipate in 1–4 years

Status quo

•

•

•

Students 8 years of age and older

Perspective: Societal

25–50 years

• QALYs •

•

•

Costs of school-based 

antitobacco education 

program and annual 

medical costs

Base year: 1999

Source: Salaries of 

educators for public 

middle school teachers, 

average class size, and 

census data

•

•

Cost-effectiveness ratios per QALY gained 

over the 50 years ranged from $4,900 

($9,294 in 2017 $), when considering a 56% 

reduction in smoking that dissipates in

4 years, to $340,000 ($644,890 in 2017 $), 

when considering a 5% reduction in 

smoking that dissipates in 1 year

For most plausible scenario of 30% reduction 

in smoking that dissipates in 4 years, the 

cost-effectiveness ratio per QALY gained over 

the 50 years was $20,000 ($37,935 in 2017 $)

Ong and Glantz 

(2005)

•

•

•

•

•

•

Monte Carlo simulation model

Cost-effectiveness and cost-utility analyses

18 years of age and older

Interventions/comparison:

–

–

A free NRT program and statewide 

smokefree workplace campaign

Common clinical standard

Perspective: Not stated

1 year

•

•

Quit rates

QALYs

• FreeNRTprogram:Average 

wholesale price forNRT, 

cost of quit attempt, cost 

oftherapy, and cost oftotal 

medication; did notinclude 

cost of administration 

• Source: Wholesale prices 

for the mostinexpensive 

NRTs 

• Smokefreeworkplace 

policy: Costs for enactment 

and reinforcement 

• Source:Occupational 

Employment Statistics 

Survey and published 

studies 

• Base year: 2001 

Free NRT program: Generated 18,500 

quitters, and the cost-effectiveness ratios were

$7,020 ($12,223 in 2017 $) per quitter and

$4,440 ($7,736 in 2017 $) per QALY gained

• Smokefree workplace policy: Generated 

10,400 quitters, and the cost-effectiveness 

ratios were $799 ($1,392 in 2017 $) per 

quitter and $506 ($882 in 2017 $) per 

QALY gained

Table 5.9 Summary of economic evaluations of nonclinical interventions for smoking cessation

The Benefits of Smoking Cessation on Overall Morbidity, Mortality, and Economic Costs 483
Study Design/population Effects Costs Outcomes/findings

Villanti et al. 

(2012)

• Cost-utility analysis

• 18- to 49-year-olds in eight designated 

markets

• Interventions/comparison:

– National EX campaign to promote 

smoking cessation

– Status quo

• Perspective: Societal

• 6 months

• QALYs • EX campaign costs (media, 

public relations, salaries, 

and recruitment) and other 

societal costs (consumer 

time and treatment costs)

• Base year: 2009

• Source: Consumer time 

lost during exposure to 

intervention and costs 

of treatment

• The EX campaign achieved 52,979 additional 

quit attempts and 4,238 additional quits, 

and saved 4,450 QALYs

• Incremental cost-utility ratios per QALY

gained ranged from $37,355 ($47,271 in

2017 $) to $81,301 ($102,883 in 2017 $)

Xu et al. (2015a) • Monte Carlo simulation model

• Cost-effectiveness and cost-utility analyses

• Quitters, 18 years of age and older

• Interventions/comparisons:

– Tips Campaign

– Without Tips Campaign

• Perspective: CDC (funding agency)

• 6 months

• Quit rates, 

premature death, 

life-years, and 

QALYs

• Cost of Tips Campaign 

(development, media 

placement, and evaluation)

• Base year: 2012

• Source: CDC Office on 

Smoking and Health’s 

budget for Tips Campaign

• Prevented 17,109 premature deaths, and 

saved approximately 179,099 QALYs

• Cost-effectiveness ratio was $480 ($550 in 

2017 $) per quitter, $2,819 ($3,229 in 2017 $) 

per premature death averted; $393 ($450 in 

2017 $) per life-year saved, and $268 ($307 in 

2007 $) per QALY gained

Table 5.9 Continued

A Report of the Surgeon General

484 Chapter 5

Notes: NRT = nicotine replacement therapy; QALYs = quality-adjusted life-years; Tips = Tips From Former Smokers Campaign. Estimates converted to 2017 dollars from 

the base case year (or publication year if no base case year) using the Medical Care part of the Consumer Price Index (all urban consumers).
The Benefits of Smoking Cessation on Overall Morbidity, Mortality, and Economic Costs 485

Smoking Cessation

Brown 2015). The new recommendations from the second 

Panel on Cost-Effectiveness in Health and Medicine, which 

were published after the publication of many of the studies 

reviewed in this chapter, emphasize the need for compliance with the recommendations for consistency and comparability of studies (Sanders et al. 2016). Additionally, 

current trends in cigarette smoking and other forms of 

tobacco product use affect estimates of economic expenditures from smoking and smoking cessation.

Nonetheless, the scientific evidence clearly documents that smoking cessation interventions reduce 

smoking-attributable expenditures. Evidence on the costeffectiveness of smoking cessation interventions is consistent across numerous studies—even when considering 

different methodologies and outcomes.

The evidence from studies of economic burden 

has shown that cigarette smoking generates substantial 

smoking-attributable healthcare expenditures and lost 

productivity, a conclusion reached in previous reports 

of the Surgeon General (USDHHS 2014). These expenditures affect the smoker specifically and society generally. Using the values per QALY discussed previously 

(USDHHS 2016), the evidence from economic evaluations that focus on the cost-effectiveness of smoking cessation interventions demonstrates that such interventions are cost-effective from various perspectives and that 

the cost-effectiveness ratio from the societal perspective 

will always be higher than from other perspectives. Taken 

together, the scientific evidence on the health and cost 

benefits of smoking cessation interventions indicates that 

these interventions should be implemented as widely 

as possible throughout the healthcare system and supported more broadly by population-level tobacco control 

measures.

Summary of the Evidence

This chapter examines morbidity, mortality, and economic costs in relation to smoking cessation. For general 

measures of health outcomes, particularly general QoL, 

there is evidence of higher levels of improvement in QoL 

among former smokers than among those who continue 

to smoke. Morbidity is higher in former smokers than in 

never smokers, but in some subgroups, morbidity among 

former smokers can approach that of never smokers, such 

as among those with lower levels of addiction at the time 

of cessation.

A causal link between smoking cessation and a 

decrease in general morbidity is supported by the biologic plausibility of the relationship. Many well-supported 

mechanisms link smoking cessation to improvements in 

more specific measures of health, such as disease-specific 

outcomes, thus underscoring the certainty that those 

who quit smoking will have lower rates of morbidity.

The health benefits of smoking cessation on allcause mortality have been covered extensively in previous 

Surgeon General’s reports. The evidence that has accumulated since the 1990 Surgeon General’s report affirms that 

smoking cessation at any age reduces the risk of premature death from a smoking-caused illness.

Cigarette smoking generates substantial smokingattributable healthcare expenditures and lost productivity. 

These expenditures affect the smoker specifically and 

society generally. The evidence from economic evaluations 

that focus on the cost-effectiveness of smoking cessation 

interventions demonstrates that such interventions are 

cost-effective from various perspectives. Taken together, 

the scientific evidence on the health and cost benefits 

of smoking cessation interventions indicates that these 

interventions should be implemented as widely as possible 

throughout the healthcare system and supported more 

broadly by population-level tobacco control measures.

Conclusions

1. The evidence is sufficient to infer that smoking cessation improves well-being, including higher quality 

of life and improved health status.

2. The evidence is sufficient to infer that smoking cessation reduces mortality and increases the lifespan.

3. The evidence is sufficient to infer that smoking

exacts a high cost for smokers, healthcare systems,

and society.

4. The evidence is sufficient to infer that smoking cessation interventions are cost-effective.
A Report of the Surgeon General

486 Chapter 5

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