, Volume 36, Issue 9, pp 1101–1112 | Cite as

Smoking Cessation: A Comparison of Two Model Structures

  • Becky PenningtonEmail author
  • Alex Filby
  • Lesley Owen
  • Matthew Taylor
Original Research Article



Most economic evaluations of smoking cessation interventions have used cohort state-transition models. Discrete event simulations (DESs) have been proposed as a superior approach.


We developed a state-transition model and a DES using the discretely integrated condition event (DICE) framework and compared the cost-effectiveness results. We performed scenario analysis using the DES to explore the impact of alternative assumptions.


The models estimated the costs and quality-adjusted life years (QALYs) for the intervention and comparator from the perspective of the UK National Health Service and Personal Social Services over a lifetime horizon. The models considered five comorbidities: chronic obstructive pulmonary disease, myocardial infarction, coronary heart disease, stroke and lung cancer. The state-transition model used prevalence data, and the DES used incidence. The costs and utility inputs were the same between two models and consistent with those used in previous analyses for the National Institute for Health and Care Excellence.


In the state-transition model, the intervention produced an additional 0.16 QALYs at a cost of £540, leading to an incremental cost-effectiveness ratio (ICER) of £3438. The comparable DES scenario produced an ICER of £5577. The ICER for the DES increased to £18,354 when long-term relapse was included.


The model structures themselves did not influence smoking cessation cost-effectiveness results, but long-term assumptions did. When there is variation in long-term predictions between interventions, economic models need a structure that can reflect this.


Data Availability Statement

Both economic models are available to reviewers, subject to signing relevant forms. To request access to the Markov model, please contact NICE ( with details of your request and attach the completed confidentiality form ( To request access to the DES, please email the corresponding author.

Author Contributions

AF identified inputs for and built the Markov model, with support from MT. LO advised on the design of and inputs to the Markov model, and quality assured the final version of the model. BP identified additional inputs for and built the DES. BP wrote the first draft of this manuscript, and all co-authors reviewed and suggested changes. All authors reviewed and approved the final draft.

Compliance with Ethical Standards


When this work was undertaken, Becky Pennington and Lesley Owen were employed by the NICE. Alex Filby and Matthew Taylor were employed by York Health Economics Consortium, who received payment from the NICE to build the state-transition model. The DICE simulation framework shell was made available by Evidera. Authors received no funding from Evidera.

Conflict of interest

Becky Pennington reports no conflicts of interest. Lesley Owen reports no conflicts of interest. Alex Filby reports no conflicts of interest. Matthew Taylor reports no conflicts of interest

Supplementary material

40273_2018_657_MOESM1_ESM.docx (13 kb)
Supplementary material 1 (DOCX 13 kb)


  1. 1.
    Brennan A, Chick S, Davies R. A taxonomy of model structures for economic evaluation of health technologies. Health Econ. 2006;15:1295–310. Scholar
  2. 2.
    Roberts M, Russell L, Paltiel A, Chambers M, McEwan P. Modeling good research practices—overview: a report of the ISPOR-SMDM Modeling Good Research Practices Task Force-2. Value Health. 2012;15:804–11. Scholar
  3. 3.
    Briggs A, Wolstenholme J, Blakely T, Scarborough P. Choosing an epidemiological model structure for the economic evaluation of non-communicable disease public health interventions. Popul Health Metr. 2016;14(17):1–12. Scholar
  4. 4.
    Ethgen O, Standaert B. Population- versus cohort-based modelling approaches. Pharmacoeconomics. 2012;30(3):171–81. Scholar
  5. 5.
    Davis S, Stevenson M, Tappenden P, Wailoo A. Cost-effectiveness modelling using patient-level simulation. NICE DSU Tech Support Doc. 2014;15(April):1–62.Google Scholar
  6. 6.
    Caro J. Discretely integrated condition event (DICE) simulation for pharmacoeconomics. Pharmacoeconomics. 2016;34(7):665–72. Scholar
  7. 7.
    Möller J, Davis S, Stevenson M, Caro J. Validation of a DICE simulation against a discrete event simulation implemented entirely in code. Pharmacoeconomics. 2017;35(10):1103–9. Scholar
  8. 8.
    Scarborough PV, Bhatnagar P, Kaur A, Leal J, Luengo-Fernandez R, Gray A, Rayner M, Allender S. Stroke statistics. 2009. Accessed Sep 2017.
  9. 9.
    NHS Digital. Health Survey for England, 2014: trend tables. 2015. Accessed 13 Sep 2017.
  10. 10.
    Getsios D, Marton J, Revankar N, Ward A, Willke R, Rublee D, et al. Smoking cessation treatment and outcomes patterns simulation: a new framework for evaluating the potential health and economic impact of smoking cessation interventions. Pharmacoeconomics. 2013;31(9):767–80. Scholar
  11. 11.
    Berg M, Cheung K, Hiligsmann M, Evers S, de Kinderen R, Puttarin K, et al. Model-based economic evaluations in smoking cessation and their transferability to new contexts: a systematic review. Addiction. 2017;112(6):946–67. Scholar
  12. 12.
    Bolin K. Economic evaluation of smoking-cessation therapies: a critical and systematic review of simulation models. Pharmacoeconomics. 2012;30(7):551–64. Scholar
  13. 13.
    Jit M, Barton P, Chen YF, Uthman O, Aveyard P, Meads C. School‐based interventions to prevent the uptake of smoking among children and young people: cost-effectiveness review. 2009. Accessed Jan 2018.
  14. 14.
    van Hout BA, Hummel S, Freeman C, Messina J, Rees A, Goyder E. Costs and effects of strategies to support quitting the use of smokeless tobacco. Accessed Jan 2018.
  15. 15.
  16. 16.
    Taylor M, Lewis L. An economic evaluation of different interventions to promote harm reduction. 2012. Accessed 26 Jan 2018.
  17. 17.
    Mallender J, Bertranou E, Bacelar M, Roberts S. Economic analysis of smoking cessation in secondary care. In: 2013. 2013. Accessed Sep 2017.
  18. 18.
    Parrott S, Godfrey C, Kind P. Cost-effectiveness of brief intervention and referral for smoking cessation. 2006. Accessed Jan 2018.
  19. 19.
    Raikou M, McGuire A. Cost-effectiveness of a mass media campaign and a point of sale intervention to prevent the uptake of smoking in children and young people: economic modelling report. 2008. Accessed Feb 2018.
  20. 20.
    National Institute for Health and Care Excellence. Developing NICE guidelines: the manual. In: Process and methods guides. 2014. Accessed Oct 2017.
  21. 21.
    Blondal T, Gudmundsson L, Olafsdottir I, Gustavsson G, Westin A. Nicotine nasal spray with nicotine patch for smoking cessation: randomised trial with six year follow up. Bmj. 1999;318(7179):285–8. Scholar
  22. 22.
    York Health Economics Consortium. Smoking cessation interventions and services. 2017. Accessed Jan 2018.
  23. 23.
    Taylor Matthew, Leonardi-Bee Jo, Agboola Shade, McNeill Ann, Coleman T. Cost effectiveness of interventions to reduce relapse to smoking following smoking cessation. Addiction. 2011;106(10):1819–26. Scholar
  24. 24.
    Vogl M, Wenig CM, Leidl R, Pokhrel S. Smoking and health-related quality of life in English general population: implications for economic evaluations. BMC Public Health. 2012;12(1):203. Scholar
  25. 25.
    Hoogenveen R, van Baal P, Boshuizen H, Feenstra T. Dynamic effects of smoking cessation on disease incidence, mortality and quality of life: the role of time since cessation. Cost Eff Resource Alloc C/E. 2008;6:1–15. Scholar
  26. 26.
  27. 27.
    Doll R, Peto R, Wheatley K, Gray R, Sutherland I. Mortality in relation to smoking: 40 years’ observations on male British doctors. BMJ (Clin Res Ed). 1994;309:901–11. Scholar
  28. 28.
    Doll R, Peto R, Boreham J, Sutherland I. Mortality in relation to smoking: 50 years’ observations on male British doctors. BMJ (Clin Res Ed). 2004;328(7455):1519. Scholar
  29. 29.
    Leaviss J, Sullivan W, Ren S, Everson-Hock E, Stevenson M, Stevens J, et al. What is the clinical effectiveness and cost-effectiveness of cytisine compared with varenicline for smoking cessation? A systematic review and economic evaluation. Health Technol Assess. 2014;18(33):1–119. Scholar
  30. 30.
    Office for National Statistics. Weekly provisional figures on deaths registered in England and Wales. 2016. Accessed Jan 2018.
  31. 31.
    National Institute for Health and Care Excellence. Varenicline for smoking cessation. 2007. Accessed 13 Mar 2018.
  32. 32.
    National Institute for Health and Care Excellence. Stop smoking services. 2013. Accessed 13 Mar 2018.
  33. 33.
    Claxton L, Malcom WA, Hodgson R. A comparison of modelling techniques: patient simulation verse Markov modelling in ophthalmology. Value Health. 2014;17(7):A558–9.CrossRefPubMedGoogle Scholar
  34. 34.
    Simpson KN, Strassburger A, Jones WJ, Dietz B, Rajagopalan R. Comparison of Markov model and discrete-event simulation techniques for HIV. Pharmacoeconomics. 2009;27(2):159–65. Scholar
  35. 35.
    Stevenson M, Archer R, Tosh J, Simpson E, Everson-Hock E, Stevens J, et al. Adalimumab, etanercept, infliximab, certolizumab pegol, golimumab, tocilizumab and abatacept for the treatment of rheumatoid arthritis not previously treated with disease-modifying antirheumatic drugs and after the failure of conventional disease-modifying antirheumatic drugs only: systematic review and economic evaluation. Health Technol Assess. 2016. Scholar
  36. 36.
    Chaiton MDL, Cohen JE, Bondy SJ, Selby P, Philipneri A, Schwartz R. Estimating the number of quit attempts it takes to quit smoking successfully in a longitudinal cohort of smokers. BMJ Open. 2016;6(6):011045. Scholar
  37. 37.
    Standfield L, Comans T, Scuffham P. Markov modeling and discrete event simulation in health care: a systematic comparison. Int J Technol Assess Health Care. 2014;30(2):165–72. Scholar
  38. 38.
    West R, Fidler J. Smoking and smoking cessation in England 2010. 2011. Accessed Jan 2018.
  39. 39.
    Pluvy I, Panouilleres M, Garrido I, Pauchot J, Saboye J, Chavoin J, et al. Smoking and plastic surgery, part II. Clinical implications: a systematic review with meta-analysis. Ann Chir Plast Esthet. 2015;60(1):e15–49. Scholar
  40. 40.
    Sorensen LT. Wound healing and infection in surgery: the pathophysiological impact of smoking, smoking cessation, and nicotine replacement therapy: a systematic review. Ann Surg. 2012;255(6):1069–79. Scholar
  41. 41.
    National Clinical Guideline Centre. Venous thromboembolism: reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients admitted to hospital. London. 2010. Accessed Sep 2017.
  42. 42.
    Tengs T, Wallace A. One thousand health-related quality-of-life estimates. Med Care. 2000;38(6):583–637.CrossRefPubMedGoogle Scholar
  43. 43.
    Myint PK, Sinha S, Luben RN, Bingham SA, Wareham NJ, Khaw K-T. Risk factors for first-ever stroke in the EPIC-Norfolk prospective population-based study. Eur J Cardiovasc Prev Rehabilit. 2008;15(6):663–9. Scholar
  44. 44.
    Bhatnagar P, Wickramasinghe K, Williams J, Rayner M, Townsend N. The epidemiology of cardiovascular disease in the UK 2014. Heart (Br Card Soc). 2015. Scholar
  45. 45.
    UK. CR. Lung cancer UK price tag eclipses the cost of any other cancer. 2012. Accessed 13 Sep 2017.
  46. 46.
    Pesch B, Kendzia B, Gustavsson P, Jöckel K-H, Johnen G, Pohlabeln H. Cigarette smoking and lung cancer–relative risk estimates for the major histological types from a pooled analysis of case-control studies. Int J Cancer. 2012;131(5):1210–9. Scholar
  47. 47.
    Maddams J, Brewster D, Gavin A, Steward J, Elliott J, Utley M, et al. Cancer prevalence in the United Kingdom: estimates for 2008. Br J Cancer. 2009;101:541–7. Scholar
  48. 48.
  49. 49.
    Godfrey C, Ali S, Parrott S, Pickett K. Economic model of adult smoking related costs and consequences for England. 2011. Accessed Jan 2018.
  50. 50.
    Prescott E, Hippe M, Schnohr P, Hein H, Vestbo J. Smoking and risk of myocardial infarction in women and men: longitudinal population study. BMJ (Clin Res Ed). 1998;316(7137):1043–7. Scholar
  51. 51.
    Townsend N, Wickramasinghe K, Bhatnagar P, Smolina K, Nichols M, Leal J et al. Coronary heart disease statistics. 2012. Accessed Jan 2018.
  52. 52.
    Townsend N, Bhatnagar P, Wilkin E, Wickramasinghe K, Rayner M. Cardiovascular disease statistics 2015. 2015. Accessed Jan 2018.
  53. 53.
    Stevanovic J, Pechlivanoglou P, Kampinga MA, Krabbe PF, Postma MJ. Multivariate meta-analysis of preference-based quality of life values in coronary heart disease. PLoS One. 2016;11(3):e0152030. Scholar
  54. 54.
    Liu J, Maniadakis N, Gray A, Rayner M. The economic burden of coronary heart disease in the UK. Heart (Br Card Soc). 2002;88(6):597–603. Scholar
  55. 55.
    National Clinical Guideline Centre. Chronic obstructive disease: management of chronic obstructive pulmonary disease n adults in primary and secondary care. 2010. Accessed Sep 2017.
  56. 56.
    Rutten-van Mölken M, Oostenbrink J, Tashkin D, Burkhart D, Monz B. Does quality of life of COPD patients as measured by the generic EuroQol five-dimension questionnaire differentiate between COPD severity stages? Chest. 2006;130(4):1117–28. Scholar
  57. 57.
    Løkke A, Lange P, Scharling H, Fabricius P, Vestbo J. Developing COPD: a 25 year follow up study of the general population. Thorax. 2006;61(11):935–9. Scholar
  58. 58.
    Association of Public Health Observatories. COPD Prevalence Estimates Dec 2011. 2011. Accessed Jan 2018.
  59. 59.
    British Lung Foundation. Chronic obstructive pulmonary disease statistics. 2016. Accessed 13 Sep 2017.
  60. 60.
    Curtis L BA. Unit costs of health and social care 2015. 2015. Accessed Jan 2018.
  61. 61.
    Bolin K, Wilson K, Benhaddi H, de Nigris E, Marbaix S, Mork AC, et al. Cost-effectiveness of varenicline compared with nicotine patches for smoking cessation–results from four European countries. Eur J Public Health. 2009;19(6):650–4CrossRefPubMedGoogle Scholar
  62. 62.
    Shields M, Wilkins K. Smoking, smoking cessation and heart disease risk: a 16-year follow-up study. Health Reports. 2013;24(2):12–22PubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.School of Health and Related ResearchUniversity of SheffieldSheffieldUK
  2. 2.National Institute for Health and Care ExcellenceLondonUK
  3. 3.York Health Economics Consortium, Enterprise HouseUniversity of YorkYorkUK

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