Background: Tobacco use is the leading preventable cause and modifiable risk factor associated with head and neck cancer (HNC). Beyond the direct health hazards associated with its use, tobacco expenditures may supplant spending on health-promoting behaviors and have been associated with decreased spending on housing, food and clothing, and increased food insecurity. As such, tobacco use and associated spending may exacerbate financial toxicity (FT) related to cancer treatment, with implications on oncologic outcomes and mortality. However, no studies have investigated the relationship of tobacco use and FT in patients with HNC. In this study, we systematically reviewed the literature on the financial burden of tobacco use and cessation in smoking-related cancers.
Methods: A systematic review was performed according to PRISMA guidelines. Multiple databases were queried using the terms "tobacco dependence', "smoking cessation', "financial toxicity', "cancer' and all relevant synonyms. Peer-reviewed studies were included if they measured any financial cost related to tobacco use or cessation in populations with smoking-related cancers, including but not limited to lung and HNC. Citations were excluded if they were a review, abstract, editorial, or in a foreign language. All costs were converted to U.S. Dollars and adjusted for inflation.
Results: Among 1165 identified articles, 37 met inclusion criteria, representing 33 countries across 5 continents [study types: economic model (n=27), retrospective cohort (n=7), prospective randomized (n=1), mixed-methods (n=1), randomized control trial (n=1)]. Although most studies included patients who smoke with any type of cancer, 13.6% focused on HNC and 9.0% on lung cancer. Regarding tobacco use, outcomes were direct and indirect medical costs for treating smoking-attributable cancers, hospital expenditures, and additional treatment costs in cancer patients who continued smoking. For tobacco cessation, outcomes were healthcare cost savings, cessation intervention cost-effectiveness, and incremental cost-effectiveness ratio from cessation (ICER) for quality-adjusted life years (QALY) gained. Annual direct costs for treating smoking-related cancers ranged between $5,074–52,106/patient and $3.8 million–23.8 billion/country. Annual indirect costs amounted to $43,224/individual. Patients who continued smoking after their cancer diagnosis incurred an average of $7,507 (range $4,335–10,678) in total additional medical costs. One country's public health burden from a single hospitalization for smoking-associated oral cancer was estimated to reach $16.4 million ($32,817/patient) by 2026. The cost of cessation interventions ranged between $4–25,329/participant, the average cost/quit was $6,277 (range $2,688–9,866), and the average ICER (Δcost/ΔQALY) was $14,680 (range $3,903–52,067). Healthcare cost savings up to $470 million/year were realized in some countries due to smoking cessation. Providing financial incentives for smoking cessation in patients with HNC proved unsuccessful.
Conclusion: Tobacco use has a substantial financial impact on patients, health systems, and governments. Current cessation efforts vary dramatically by cost and design, yet they appear to be cost-effective both at the individual and societal level. Further work is needed to elucidate the role of tobacco spending on FT in cancer care to develop tobacco cessation interventions which reduce both the health and financial harms of tobacco dependence.