Mixed-methods Economic Evaluation of the Implementation of Tobacco Treatment Programs in National Cancer Institute-designated Cancer Centers
Authors: Salloum Ramzi G. , D'Angelo Heather , Theis Ryan , Rolland Betsy , Hohl Sarah , Pauk Danielle , LeLaurin Jennifer , Asvat Yasmin , Chen Li-Shiun , Day Andrew , Goldstein Adam , Hitsman Brian , Hudson Deborah , King Andrea , Lam Cho , Lenhoff Katie , Levinson Arnold , Prochaska Judith , Smieliauskas Fabrice , Taylor Kathryn , Thomas Janet , Tindle Hilary , Tong Elisa , White Justin S , Vogel Bruce , Warren Graham W , Fiore Michael 
Published: January 2021

Abstract
Background: The Cancer Center Cessation Initiative (C3I) was launched in 2017 as a part of the NCI Cancer Moonshot program to assist NCI-designated cancer centers in developing tobacco treatment programs for oncology patients. Participating centers have implemented varied evidence-based programs that fit their institutional resources and needs, offering a wide range of services including in-person and telephone-based counseling, point of care, interactive voice response systems, referral to the quitline, text- and web-based services, and medications.Methods: We used a mixed methods comparative case study design to evaluate system-level implementation costs across 15 C3I-funded cancer centers that reported for at least one six-month period between July 2018 and June 2020. We analyzed operating costs by resource category (e.g., personnel, medications) concurrently with transcripts from semi-structured key-informant interviews conducted during site visits. Personnel salary costs were estimated using Bureau of Labor Statistics wage data adjusted for area and occupation, and non-wage benefits. Qualitative findings provided additional information on intangible resources and contextual factors related to implementation costs.Results: Total monthly operating costs across funded centers ranged from $6,453 to $20,751. The largest operating cost category was personnel ($4,122-$19,794), with the highest personnel costs attributable to the provision of in-person program services. Monthly cost ranges for other categories were: medications ($17-$573), materials ($6-$435), training ($96-$516), technology ($171-$2,759), and equipment ($10-$620). Cost-per-participant ranged from $70 to $3,500 (median, $537) and cost-per-quit ranged from $330 to $9,799 (median, $2,699) with sites offering different combinations of program components, ranging from individually-delivered in-person counseling only to one program that offered all components. Site interviews provided context for understanding variations in program components and their cost implications.Conclusions: Among most centers that have progressed in tobacco treatment program implementation, cost-per-quit was modest relative to other prevention interventions. Although select centers have achieved similar average costs by offering program components of various levels of intensity, they have varied widely in program reach and effectiveness. Evaluating implementation costs of such programs alongside reach and effectiveness is necessary to provide decision makers in oncology settings with the important additional information needed to optimize resource allocation when establishing tobacco treatment programs.