Smoking Cessation Adjuncts Are Cost Effective Prior to Elective Revascularization

Background: Preoperative smoking cessation can reduce adverse postoperative outcomes. Investment in smoking cessation therapies has therefore proven cost effective prior to elective interventions across numerous disciplines. Despite high rates of smoking among patients with peripheral artery disease (PAD), the cost effectiveness of smoking cessation before elective revascularization is unclear. Methods: Using a Markov model, we evaluated the cost effectiveness of preoperative smoking cessation therapies (standard care, counseling, nicotine replacement therapy [NRT], varenicline, bupropion) for 65-year-old patients undergoing open or endovascular revascularization for symptomatic PAD. Local data quantified smoking cessation therapy costs. Established literature informed therapy effectiveness, postoperative outcomes (stroke, myocardial infarction, major amputation, patency, death) frequencies, and postoperative costs. Lifetime costs were quantified in US dollars and effectiveness in quality-adjusted life-years (QALYs), with a willingness-to-pay threshold of $100,000/QALY gained. Sensitivity analyses tested model robustness. Results: In the base-case scenario, standard care was least expensive ($326,280) and varenicline was costliest ($333,335). However, varenicline was the most effective (7.11 QALYs), while standard care was least effective (6.43 QALYs). NRT and varenicline were the most cost-effective therapies. In the probabilistic simulation (randomly varying model parameters over 1,000 iterations), varenicline was favored in 80.3% at $100,000/QALY gained. Assuming no mortality differences by smoking status, in one-way sensitivity analyses varenicline dominated all other therapies. Conclusion: Smoking cessation adjuncts are cost effective prior to PAD interventions. Varenicline and NRT were the most cost-effective smoking cessation strategies. Our results highlight the value of supplemented coverage for smoking cessation therapies among patients with PAD undergoing revascularization.