Comparative cost-effectiveness of policy instruments for reducingthe global burden of alcohol, tobacco and illicit drug use
DAN CHISHOLM1, CHRIS DORAN2, KENJI SHIBUYA1, & JURGEN REHM3
1Evidence and Information for Policy, World Health Organisation, Geneva, Switzerland, 2School of Population Health,
University of Queensland, Brisbane, Queensland, Australia, and 3Centre for Addiction and Mental Health, Toronto,
Canada
AbstractAlcohol, tobacco and illicit drug use together pose a formidable challenge to international public health. Building on earlierestimates of the demonstrated burden of alcohol, tobacco and illicit drug use at the global level, this review aims to consider thecomparative cost-effectiveness of evidence-based interventions for reducing the global burden of disease from these three riskfactors. Although the number of published cost-effectiveness studies in the addictions field is now extensive (reviewed briefly here)there are a series of practical problems in using them for sector-wide decision making, including methodological heterogeneity,differences in analytical reference point and the specificity of findings to a particular context. In response to these limitations, amore generalised form of cost-effectiveness analysis (CEA) is proposed, which enables like-with-like comparisons of the relativeefficiency of preventive or individual-based strategies to be made, not only within but also across diseases or their risk factors.The application of generalised CEA to a range of personal and non-personal interventions for reducing the burden of addictivesubstances is described. While such a development avoids many of the obstacles that have plagued earlier attempts and in sodoing opens up new opportunities to address important policy questions, there remain a number of caveats to population-levelanalysis of this kind, particularly when conducted at the global level. These issues are the subject of the final section of thisreview. [Chisholm D, Doran C, Shibuya K, Rehm J. Comparative cost-effectiveness of policy instruments forreducing the global burden of alcohol, tobacco and illicit drug use. Drug Alcohol Rev 2006;25:553 – 565]
Key words: alcohol, cost effectiveness, illicit drug, policy, tobacco.
Introduction
The global disease burden of alcohol, tobacco
and illicit drug use
Alcohol, tobacco and illicit drug use together pose a
formidable challenge to international public health.
Whether expressed in epidemiological, economic or
social terms, the combined burden or impact of these
three lifestyle behaviours is enormous. Rates of use or
consumption of course vary across countries and
indeed whole regions of the world, both in terms of
absolute aggregate burden and in terms of the relative
contribution of alcohol, tobacco and illicit drug use to
these aggregated estimates, but nowhere could be said
to be at all free of the often pernicious consequences
placed on society by these lifestyle behaviours.
Studies of the economic and social impact of sub-
stance abuse are plentiful in number, but are essentially
restricted to high-income countries which, together with
significant differences in the methodology used to
estimate costs, limit their usefulness at the global level.
Nevertheless, country-specific studies have demon-
strated the enormous toll on health and welfare services,
as well as broader social impacts including reduced
productivity resulting from morbidity or premature
mortality, and the effects of alcohol or illicit drug use
on rates of domestic violence or criminal behaviour
[1 – 3]. For example, Single et al. [1] estimated that the
misuse of alcohol, tobacco and illicit drugs cost more
Received 12 March 2006; accepted for publication 19 May 2006.
Dan Chisholm PhD, Evidence and Information for Policy, World Health Organisation, Geneva, Switzerland, Chris Doran PhD, School ofPopulation Health, University of Queensland, Brisbane, Australia, Kenji Shibuya PhD, Evidence and Information for Policy, World HealthOrganisation, Geneva, Switzerland, and Jurgen Rehm PhD, Centre for Addiction and Mental Health, Toronto, Canada. Correspondence toDr Dan Chisholm, Health Economist, Costs, Effectiveness, Expenditures and Priority-setting, Department of Health System Financing, Evidenceand Information for Health Policy, World Health Organisation, 1211 Geneva 27, Switzerland. Tel: þ 41 22 791 4938; Fax: þ 41 22 791 4328;E-mail: [email protected]
Drug and Alcohol Review (November 2006), 25, 553 – 565
ISSN 0959-5236 print/ISSN 1465-3362 online/06/060553–13 ª Australasian Professional Society on Alcohol and Other Drugs
DOI: 10.1080/09595230600944487
than Canadian $18.4 billion in 1992, representing $649
per capita or 2.7% of gross domestic product.
At a more genuinely global and comparative level, the
World Health Organisation has quantified the epide-
miological burden associated with alcohol, tobacco and
illicit opioid use as risk factors for disease in different
regions of the world using disability-adjusted life-years
(DALYs) [4]; see also the review by Rehm et al., this
issue). Figure 1 shows the combined burden for three
mega-regions: developed regions with very low child
and adult mortality (representing 22% of the world’s
population); developing regions with low child and
adult mortality (39%); and developing regions with high
or very high child and adult mortality (39%). Even at
this highly aggregate level of estimation, it is clear that
the burden—70% of which is incurred among the
(adolescent and adult) male population—represents a
public health challenge everywhere, even in high-
mortality developing regions (4% of total burden).
It is arguably in this latter groups of countries, where
fledgling markets are strongest and regulatory struc-
tures weakest, that most attention should be paid to
controlling rates of hazardous drinking and preventing
the transition to more elevated stages of the tobacco
epidemic.
Reducing the global burden of alcohol, tobacco
and illicit drug use
Once the attributable burden of alcohol, tobacco and
illicit drug use has been established, two subsequent
questions for decision-making and priority-setting relate
to avoidable burden (the proportion of attributable
burden that could be avoided via scaled-up use of effec-
tive strategies; [5]) and resource efficiency (determining
the most cost-effective ways of reducing burden).
Building on earlier methods and estimates of the
epidemiological burden of addictive substances at the
global level [4 – 6]; see also Rehm et al., this issue), this
review aims to consider the comparative cost-effective-
ness of evidence-based interventions for reducing the
global burden of disease from these three risk factors.
Concerning illicit drug use, cannabis use accounts for
around 80% of illicit drug use world-wide, but the
focus here is on opioid dependence, because it repre-
sents the major illicit drug problem in most regions of
Figure 1. Global disease burden attributable to addictive substances in 2000 (DALYs per thousand population, by level of development, sex
and risk factor). There may be double counting due to interactions in causing some cancer and injury categories. Thus, the combined estimates
of adding the burden of all three substances represent an overestimate. However, the impact of the categories affected by double counting on the
overall estimate is relatively small. For Australia in 1998 – 99, it was estimated that double counting lead to an overestimate of 2.2% of the
total mortality caused by addictive substances [3]. Based on this estimate, the overall effect of alcohol, tobacco and illicit drugs would be 20.19
DALYs lost per 1000 population rather than 20.64 as indicated in the figure (last column). Source: Annex Tables 10 and 12, World Health
Report, 2002 [4].
554 Dan Chisholm et al.
the world in terms of impact on public health and
public order [7].
In order to achieve this aim, a fundamental analytical
requirement is the presence of a standardised evaluative
methodology which can be used to generate consistent
estimates of cost, effect, or their interaction in terms of
cost-effectiveness. Such a standardised method has
been hard to attain, which has effectively confounded
attempts to systematically compare the efficiency of
different interventions across or even within the three
risk factors considered here. As illustrated below,
however, such a method is now available, as a result
of developments in the health sector-wide analysis of
cost-effectiveness, and it has been applied to a number
of key alcohol and tobacco control strategies [8,9].
Preliminary use of these methods has also been partially
extended to the treatment of opioid dependence, results
from which are included here. Analyses such as these
mean that like-with-like comparisons of the relative
efficiency of preventive or individual-based strategies
are now technically feasible, not only within but also
across diseases or their risk factors. While such a
development avoids many of the obstacles that have
plagued earlier attempts and in so doing opens up new
opportunities to address important policy questions,
there remain a number of important caveats to
population-level analysis of this kind, particularly when
conducted at the global level. These issues are the
subject of the final section of this review.
Current cost-effectiveness methods
and results for addictions policy
Current economic evidence related to addictive substances
In the necessarily brief review of the accumulated
literature to date that now follows on the cost-
effectiveness of interventions for reducing the burden
of tobacco, alcohol and opioid dependence, we dis-
tinguish between personal interventions—such as brief
counselling, nicotine replacement therapy and opioid
detoxification—and non-personal interventions such as
excise taxation, advertising bans and clean indoor air
laws, with a view to drawing out key empirical findings
and methodological differences among studies.
Personal interventions
Alcohol. A distinction needs to be made between
personal interventions targeted on the disease entity of
alcohol dependence versus hazardous drinking (a risk
factor for many diseases including but not restricted to
alcohol dependence). Cost-effectiveness analysis of
treatments for alcohol dependence have covered psy-
chosocial treatments such as motivational enhancement
therapy and medications such as acamprosate or
disulfiram [10,11], but are not the focus for this
review, which deals specifically with the globally
more burdensome problem of hazardous or high-risk
alcohol use.
The only personal intervention aimed at hazardous
drinking that has been subjected to economic evaluation
is brief advice or counselling by a primary care physician
[12]. Using effectiveness results from the WHO’s
Drink-less programme, Wutzke et al. [13] estimated
the cost-effectiveness of different strategies for reducing
alcohol consumption (in Australian dollars). Compared
to a do-nothing scenario, the cost per life-year saved was
estimated to be AUS $645 for a control group (no initial
training or ongoing support), AUS $581 for a no-
support group (5 minutes of initial training with no
further contact or support) and AUS $653 for a
maximal-support group (5 minutes training plus alter-
nate telephone and personal visits every 2 weeks).
In a US primary care setting, Fleming et al. [14]
undertook an economic evaluation of brief physician
advice for problem drinkers, in which patient and health
care costs were compared to the monetised benefits
associated with reductions in emergency department
and hospital use, crime and motor vehicle accidents
(reductions in consumption, although substantial, were
not monetised). Summing the total economic costs and
benefits, the average benefit per subject was $1151 and
the ratio of benefits to costs was more than 5 to 1.
Tobacco. Concerning tobacco control, a substantial
evidence base exists for the cost-effectiveness of smok-
ing cessation programmes (in high-income countries at
least), covering brief counselling as well as pharmaco-
logical interventions such as bupropion and various
nicotine replacement therapies (NRT). A recent sys-
tematic review included no less than 17 economic
studies [15], and concluded that between 1 and 3 life-
years are saved per quitter, each of these additional years
of life achieved at quite a low cost (below £1000 for
NRT versus current practice, for example).
A number of studies have adopted a decision-
analytical framework in order to demonstrate the impact
of improved rates of cessation on mortality and morbi-
dity and to extend comparison beyond a placebo control
group. For example, a decision model was developed for
the UK’s National Health Service, which showed that by
comparison to advice or counselling alone, an extra year
of life saved could be obtained at an additional cost of
$1441 – 3455 for NRT, $920 – 2150 for bupropion and
$1282 – 2836 for their combination [16]. More recently
a dynamic population model applied to a Dutch popu-
lation compared the net cost (adjusted for savings from
avoided smoking-related diseases) per life-year and
QALY gained over 1, 10 and 75 years for telephone
counselling, minimal and intensive counselling by a
primary care physician, NRT and bupropion [17].
Comparative cost-effectiveness of policy instruments 555
With the exception of telephone counselling (which was
expected to be both less costly and more effective than
current practice), incremental cost-effectiveness ratios
were found to fall within a similar range (e1400 – 6200
per life-year gained, e1100 – 4900 per QALY gained).
Comparison of smoking cessation interventions to
other, non-personal interventions has rarely been
attempted, although one recently completed study did
compare the cost per QALY of NRT ($4400) with a
smoke-free policy in the work-place ($506) [18].
Opioid dependence. A wide range of approaches to assis-
ting dependent heroin users are available and include
detoxification and relapse prevention treatment pro-
grammes, therapeutic communities, out-patient drug-
free counselling and long-term opiate substitution
(or maintenance).
Using results from the National Evaluation of
Pharmacotherapies for Opioid Dependence (NEPOD)
Project in Australia, a cost-effectiveness analysis has
compared five in-patient and out-patient detoxification
methods [19]. The buprenorphine-based out-patient
detoxification method was found to be the most cost-
effective method overall, and rapid opioid detoxification
under sedation was the most cost-effective inpatient
method. Also in Australia, Doran et al. [20] compared
the cost-effectiveness of detoxification from heroin using
buprenorphine in a specialist clinic and in a shared-care
setting, and found that buprenorphine detoxification in
the shared-care setting was $17 more expensive per
patient than the costs of treatment at the clinic ($236 per
patient), but with no significant differences in outcomes.
The limited economic evaluations of drug-free
treatment have used data from observational studies
of treatment outcomes in samples of patients with
mixed substance abuse problems, including opioids.
For example, one US study calculated a range of
estimated costs for achieving an abstinent year in 408
patients treated at two different treatment facilities in
the United States [21]. For out-patients with the least
severe drug problems, the cost of an abstinent year was
$7000, whereas the same outcome in patients with
more severe problems who received long-term residen-
tial treatment cost $20 000.
Concerning the cost-effectiveness of substitutive
maintenance treatments for opioid dependence, Doran
et al. [2] conducted a cost-effectiveness analysis of
buprenorphine maintenance treatment (BMT) versus
methadone maintenance treatment (MMT), using
change in heroin-free days as the primary outcome
measure, and concluded that buprenorphine provides a
viable and cost-effective alternative to methadone in the
treatment of opioid dependence. The National Evalua-
tion of Pharmacotherapies for Opioid Dependence
(NEPOD) also evaluated a range of maintenance
treatments. The results of the cost-effectiveness analysis
suggest, for the primary outcome measure of change
in heroin-free days, that LAAM (levo-alpha-acetyl-
methadol) and MMT are statistically equivalent in
terms of cost-effectiveness while MMT (and LAAM)
are dominant treatment options compared with
BMT and naltrexone [23]. Finally, Barnett et al. [24]
measured the cost-effectiveness of addiction treatment
in terms of life-years gained or quality-adjusted life-
years and demonstrated that MMT and BMT are cost-
effective treatment options under certain conditions.
Non-personal interventions
While there is a considerable literature documenting the
social and economic costs of substance abuse, economic
analysis of the relative cost-effectiveness of different
policy instruments has rarely been attempted, hampered
by the lack of population-level data on the costs of their
implementation or their expected impact on health
outcomes. An exception to this general statement is a
comparative analysis of the cost-effectiveness of price
increases and other policies undertaken as part of a
World Bank report on the economics of tobacco control
[25]. The authors of this study used a static model to
estimate the number of smoking-attributable deaths that
could be averted by price increases (via tax), NRT and a
package of other non-price interventions such as
advertising bans and information dissemination [26].
Cost-effectiveness was expressed in terms of US dollars
per DALY saved, calculated by weighing approximated
public-sector costs against the years of health life saved.
Price increases were found to be the most cost-effective
intervention ($3 – 70 per DALY saved in low- and
middle-income regions of the world, $83 – 2771 in high-
income countries), considerably more cost-effective in
fact than either NRT ($280 – 870 and $750 – 7206,
respectively) or a package of non-price interventions
other than NRT ($36 – 710 and $696 – 13 924, respec-
tively). Although this study goes beyond others in its
attempt to generate economic evidence relevant to
policy-makers, it is heavily undermined by its assump-
tion that the costs of non-personal interventions can be
expressed adequately as a fraction of GNP (0.005 –
0.02%).
Methodological limitations of the current
economic evidence base
Although the number of published cost-effectiveness
studies in the addictions field is now extensive, briefly
and not at all comprehensively reviewed above, there are
a series of practical problems in using them for sector-
wide decision making [27,28]. The first is that most
published studies take an incremental approach,
addressing questions such as how best should small
changes (almost always increases) in resources be
556 Dan Chisholm et al.
allocated, or whether a new technology is more cost-
effective than the existing one it would replace. Tradi-
tional analysis has not been used to address whether
existing health resources are allocated efficiently, despite
evidence that in many settings current resources do not in
fact achieve as much as they could [29,30].
The second problem is that most studies are very
context-specific. The efficiency of additional investment
in an intervention aimed at a given health problem
depends partially on the level and quality of the existing
health infrastructure (including human resources). This
varies substantially across settings and is related to a
third problem—individual interventions are almost
always evaluated in isolation despite the fact that the
effectiveness and costs of most will vary according to
whether other related interventions are currently under-
taken or are likely to be introduced in the future.
A fourth methodological limitation all too apparent
from the cursory review above relates to the multiplicity
of health outcome measures used, ranging from the
very specific (change in heroin-free days, for example)
to the very generic (life-years saved or quality-adjusted
life-years gained). This makes it quite impossible to
compare the efficiency of different interventions against
a common standard. Related to this is the decision to
include or exclude other, non-health outcomes, which
is likely to alter radically the findings and implications
of an economic evaluation. By including and measuring
in monetary terms the consequences of brief physician
advice on the incidence of criminal acts and road traffic
collisions, for example, Fleming et al. [14] provide a
very different perspective—a cost – benefit approach—
and set of findings to studies that only considered direct
health effects of brief interventions.
Two final concerns relate to uncertainty and scale
effects. Although there is now increasing attention
given to uncertainty in the theoretical literature on cost-
effectiveness analysis, full and appropriate handling of
uncertainty in published economic evaluations is still
not reported in a majority of studies [31]. This makes it
unclear how certain policy-makers can be that one
intervention is more efficient than another. Uncertainty
when interventions are inter-related in terms of costs
and effects is an even more complex issue. Similarly,
analysts rarely estimate costs and effects at different
levels of coverage or scale, so do not provide policy-
makers with important information about how far they
should expand (or contract) an intervention.
New developments in the generation
of economic evidence for addictions policy
Cost-effectiveness methodological framework
Until quite recently, there had been only a limited
connection made between disease burden estimates
and the generation of cost-effectiveness evidence,
despite this being an overall objective of the Global
Burden of Disease study. In response to this need,
WHO developed a form of economic evaluation called
generalised cost-effectiveness analysis (GCEA),
which—via its CHOICE project (CHOosing Interven-
tions that are Cost-Effective)—was designed to allow
policy-makers to evaluate the efficiency of the mix of
health interventions currently available and to maximise
the generalisability of results across settings [32,33]. At
the same time, it sought to rectify some of the
aforementioned problems of traditional CEA by in-
corporating interactions between interventions in terms
of costs and effects as well as by evaluating interven-
tions at different levels of coverage. GCEA allows for an
assessment of the efficiency of the current mix of
interventions by analysing all interventions and combi-
nations incremental on doing nothing, sometimes
referred to as a null or ‘do nothing’ scenario [32,33].
This does not mean assuming that no interventions
were ever undertaken, something that is not feasible or
necessary. Operationally, the counterfactual that has
been adopted in applied studies is defined in terms of
what would happen to population health if all inter-
ventions being provided now were stopped [8,9,34].
Consider Figure 2, in which two sets of interventions
are depicted, one for reducing exposure to hazardous
alcohol use, the other for reducing exposure to tobacco
use, for a region consisting of Latin American and
Caribbean countries with low levels of child and adult
mortality—designated here as AmrB ([8,9]; underlying
data are also provided in Table 1). The vertical axis is
the yearly cost of the intervention in a standardised
population of 1 million people, in international dollars,
while the horizontal axis measures health improvements
in terms of disability-adjusted life-years (DALYs)
averted. If a country could select its interventions from
scratch and if efficiency were the only objective, it would
first choose the intervention with the lowest slope first,
the lowest cost per unit of health effect (TOB4, a high
rate of taxation on tobacco products). As resources
increase it would move to TOB12 (a combination of
excise tax plus a comprehensive advertising ban), as the
slope of the line TOB4 to TOB12 is lower than that
from the origin to ALC6. Should more resources
become available, it would also purchase ALC6 (a high
rate of tax on alcoholic beverages), the most cost-
effective intervention for reducing hazardous alcohol
use, and this process continues.
Let us assume, however, that a country decided not
to tax alcohol products, relying instead on the enforce-
ment of drink-driving laws via random breath-testing of
drivers (ALC3). Traditional incremental analysis would
suggest that if new resources became available, it would
be most efficient to move from ALC3 to ALC2 (brief
physician advice for heavy drinkers), and then to the
Comparative cost-effectiveness of policy instruments 557
combination of these (ALC9). Without reference to a
common starting point (of doing nothing), however,
such an analysis fails to identify that ALC3 is an
inefficient use of resources compared to other single or
combined interventions for alcohol or tobacco control,
thereby providing decision makers with incomplete and
potentially misleading information.
Accumulated cost-effectiveness evidence for addictive
substances
Generalised CEA has been applied to a range of personal
and non-personal interventions for reducing the burden
of addictive substances. Details of the methods and data
sources employed in the calculation of population-level
costs and effects can be found elsewhere [4,8 – 9,35,36].
Here, we summarise these methods only very briefly,
and then provide results for three illustrative WHO
sub-regions, each representing one of the distinct levels
of economic development used earlier in relation to
disease burden: American sub-region AmrB (countries
with low rates of child and adult mortality, for example
Brazil or Mexico); European sub-region EurA (coun-
tries with very low child and adult mortality, for
example France or Norway); and South East Asian
sub-region SearD (countries with high child and adult
mortality, for example India or Nepal).
Analyses of alcohol and tobacco control strategies
used standard WHO – CHOICE methods and tools,
whereby burden averted via the implementation
of evidence-based interventions was compared to a
counterfactual scenario of no intervention using a state
transition population model [33]. Costs were esti-
mated using a bottom-up, ingredients approach built
up from the prices and quantities of resources needed
at the programme-level, and where appropriate
(e.g. nicotine replacement therapy, brief interventions
for heavy drinkers) at the patient- or facility-level.
Cost-effectiveness analysis of opioid dependence treat-
ments was carried out as part of the second edition of
Disease Control Priorities in Developing Countries [30],
which overlaps closely with CHOICE methodology
but uses US rather than international dollars to report
costs and removes age-weights from the estimation of
DALYs. Here, all costs are expressed in international
dollars (I$)—which seek to adjust for differences in
purchasing power and thereby facilitate comparisons
across settings—and, along with DALYs, are dis-
counted at a rate of 3%. Age-weights were not applied
to health effects for the present analysis, but previous
analyses have shown that over 20% more DALYs are
averted when these are used, due to the fact that
substance use is highest among people of working
age [8,9].
Figure 2. Costs and effects of interventions for reducing alcohol and tobacco use (WHO American subregion AmrB).
558 Dan Chisholm et al.
Ta
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Comparative cost-effectiveness of policy instruments 559
Alcohol use
Intervention analysis carried out to date relates to the
risk factor hazardous (or heavy) alcohol use—defined as
an average rate of consumption of more than 20 g pure
alcohol daily for women and more than 40 g daily for
men [37,38]—which represents at least 75% of the total
attributable burden associated with alcohol use [35].
Recent reviews of measures to reduce alcohol misuse
[12,38] assessed the quality of evidence for four types of
interventions specifically aimed at reducing high-risk
alcohol use: (1) policy and legislative interventions,
including taxation on alcohol sales, drunk-driving laws,
restricted licensing outlets and advertising control; (2)
measures to enforce these laws more effectively, for
example random breath-testing of drivers; (3) mass
media/awareness campaigns; and (4) brief interventions
with individual high-risk drinkers. Based on these
reviews, the following strategies and intervention effects
were included in the analysis [9]: drinking-driving
legislation and random breath testing, taxation on
alcoholic beverages, reduced hours of sale in retail
outlets, and advertising bans (all population-based
interventions) and so-called brief interventions (an
intervention based on personal behaviour). Mass media
or school-based awareness campaigns were omitted, on
the grounds that evidence for its effectiveness was weak,
both in terms of methodological quality and in terms of
their actual effect on consumption (use of such
interventions, however, may still be used to generate
awareness or address the right to be informed)
[12,38,39].
Results for three illustrative WHO sub-regions are
presented in Table 1. There are very substantial
differences in costs and effects (standardised to 1
million population), both between interventions and
between the three sub-regions. The most costly
interventions tend to be random breath testing (due
to the need for regular sobriety checkpoints adminis-
tered by law enforcement officers) and brief advice in
primary care (provision of the intervention itself, plus
programme costs associated with training). Other
interventions including taxation had a cost per capita
in the range I$ 0.04 – 0.45, depending in part on the
efficiency of the taxation collection system and the
degree of anti-drinking sentiment. Where the preva-
lence of heavy drinking is high (more than 5% of the
total adult population, as in Americas sub-region
AmrB and European sub-region EurA) taxation was
the most effective and cost-effective strategy (each
DALY averted costs less than I$ 500). By contrast, tax
is actually least effective and efficient in South East
Asia sub-region SearD, where low rates of heavy
consumption appear to favour more targeted ap-
proaches such as breath-testing and brief physician
advice.
Tobacco use
Countries that have adopted comprehensive tobacco
control programmes—involving a mix of interventions
including a ban on tobacco advertising, strong warnings
on packages, controls on the use of tobacco in indoor
locations, high taxes on tobacco products and health
education and smoking cessation programmes—have
had considerable success in reducing tobacco-related
mortality [25,40]. The costs and effects of each of these
strategies have been assessed [4,8]. Concerning taxa-
tion, three rates were evaluated: the current average
level across six WHO regions (a 79% mark-up), the
current maximum observed across these regions
(a mark-up of 300%) and double the current maximum
(a mark-up of 600% corresponding to a situation where
taxes account for 89% of the final retail price).
The benefits of anti-smoking interventions for
population health (in terms of DALYs) were estimated
through the impact of reduced smoking on the
incidence of cardiovascular disease, respiratory disease
and various forms of cancer. The interventions, not
surprisingly, have a larger impact on population health
in regions with a high prevalence of tobacco use,
especially those in the second or third stage of the
tobacco epidemic (including Americas sub-region
AmrB and South East Asia sub-region SearD).
As with alcohol control strategies, but to a much
lesser extent, costs and cost-effectiveness vary across the
three sub-regions shown in Table 1, not only because of
variations in exposure to tobacco but also differences in
the efficiency of the tax collection system, the degree of
anti-tobacco sentiment and the amount of smuggling. If
only one intervention can be chosen, taxation is the
intervention of choice in all regions. Not only does it
have the greatest impact on population health, but it is
also the most cost-effective option (one DALY is
averted at a cost of less than I$ 100). Taxation also
raises revenue for governments. To achieve greater
improvements in population health, the combination of
taxation, comprehensive bans on advertising, and
information dissemination activities would be affordable
and cost-effective in all of the sub-regions illustrated
here. Although nicotine replacement therapy is not a
very cost-effective intervention, and would considerably
add to the cost of other anti-smoking activities, the
additional expense would be justified on purely cost-
effectiveness grounds in higher-income sub-regions.
Opioid dependence
Concerning the potentially avoidable disease burden
from opioid dependence, two pharmacological mainte-
nance treatments have been assessed using a cost-per-
DALY method (methadone and buprenorphine; MMT
and BMT). Oral methadone maintenance treatment
560 Dan Chisholm et al.
(MMT) substitutes a long-acting, orally administered
opioid for (the shorter-acting) heroin, with the aim of
stabilising dependent heroin users so that they are amena-
ble to rehabilitation. Buprenorphine is a mixed agonist –
antagonist that also blocks the effects of heroin. Meta-
analyses have found that buprenorphine is effective in the
treatment of heroin dependence [41] and of equivalent
efficacy to MMT when delivered in primary health care
and specialist treatment settings in Australia [42].
For the disease modelling exercise, prevalence data
and population attributable fractions related to opioid
dependence were taken from the comparative risk
assessment [43]. Using a baseline treatment coverage
rate of 50%, maintenance treatment is estimated to
reduce the average level of disability associated with
opioid dependence by a quarter, and mortality by 25%
(methadone) and 20% (buprenorphine), respectively
[36]. Cost estimates were based on an earlier economic
evaluation [22], which estimated the cost of MMT at
AUS $1415 and BMT at AUS $1729 for 6 months of
treatment. These estimates were subsequently con-
verted into international dollars and annual estimates of
treatment cost.
Results are presented in Table 1. There are again
quite wide discrepancies in DALYs averted between
regions, which primarily reflect differences in popula-
tion attributable fractions. The cost-effectiveness ana-
lysis suggests that for MMT the cost per DALY averted
ranges from a low of I$ 458 in America’s sub-region
AmrB to more than I$ 2500 in South East Asia sub-
region SearD. Because the methods and data used to
estimate avoidable DALYs are subject to certain
limitations (see Discussion), the results should be
considered preliminary.
Sectoral comparison of intervention cost-effectiveness
for addictions control
Use of a standardised approach to the evaluation of
costs and effects provides the opportunity to make like-
with-like comparisons of interventions across different
health conditions. Figure 3 depicts the costs, effects and
cost-effectiveness of selected interventions for reducing
alcohol, tobacco and drug use for one of the regions
discussed above, WHO European sub-region EurA
(countries with a combined population of 410 million
that have very low rates of child and adult premature
mortality). Here, costs and effects are plotted on a
logarithmic scale in order to provide a ‘bird’s eye’ view
of the comparative cost-effectiveness of the various
Figure 3. Costs, effects and cost-effectiveness of selected interventions for reducing alcohol, tobacco and drug use in WHO European sub-
region EurA. Note: Perforated diagonal lines are cost-effectiveness isoquants, each of which represents one order of magnitude difference in the
cost associated with one averted DALY. For example, interventions falling below the isoquant closest to the south-east corner have a cost-
effectiveness ratio below I$ 100 per DALY averted. Source: see Table I.
Comparative cost-effectiveness of policy instruments 561
strategies. Each diagonal isoquant represents one order
of magnitude difference in cost-effectiveness terms,
ranging in this instance from I$ 100 – 10 000 per DALY
averted. While lacking precision, use of such a broad-
brush perspective can usefully inform policy-makers
about what really makes a difference and what does not,
and in fact may represent a more appropriate informa-
tion set than exact ratios given the inherent uncertainty
surrounding point estimates of cost-effectiveness.
In this region of Europe, for example, total costs and
total effects per 1 million population vary substantially
(for example, cost per capita ranges from I$ 0.2 to more
than I$ 4, while effects range from a few hundred to a
few thousand DALYs). Taxation has the highest impact
on population health and the lowest cost of implemen-
tation (cost per DALY 5 I$ 500), while personal inter-
ventions such as nicotine replacement therapy, brief
physician advice and opioid maintenance treatment are
the least cost-effective (cost per DALY 4 I$ 1000).
Although such findings may appear intuitively obvious
in a population with relatively high rates of substance
abuse, this analysis provides some underlying evidence
for these pre-sentiments.
Discussion
The limits and limitations of economic modelling
At the methodological level, the application of a broad
sectoral approach using whole regions of the world as
the unit of analysis clearly places important limits on its
use in specific country contexts, as demographic,
epidemiological or treatment characteristics may not
coincide with estimates for the region as a whole. In
addition, extrapolation of intervention effect sizes from
relatively information-rich countries to other socio-
cultural settings lessens the precision of derived
estimates of population-level health gain. Work is now
under way in a number of developed and developing
countries to ‘contextualise’ regional estimates down to
the national level, whereby local investigators replace
regional epidemiological rates, cost estimates and effect
sizes with locally derived values [28].
A further methodological issue that invariably courts
its fair share of debate is the use of the DALY, both as a
summary measure of population health and as a
primary measure of intervention outcome [45]. Some
of the most heated debate is around issues that can be
rather easily dealt with (such as use or not of age
weights and the preferred discount rate), but there
remain important constraints concerning the scope of
DALYs as an outcome measure, such as its inability to
capture potential health gains beyond the person at-
risk (such as informal caregivers). As a strictly
health-related measure, by definition it is also not
equipped to capture non-health outcomes, which in the
context of substance abuse may constitute an im-
portant component of the relative superiority of one
intervention over another.
On this note, there remain considerable challenges in
the appropriate measurement of certain societal costs
and effects falling outside the boundaries of the health
system. Thus, the present analysis has not been able to
capture potential reductions in (work-force and house-
hold) productivity losses among high-risk drinkers or
illicit drug users, nor does it incorporate the economic
costs associated with addiction-related crime, violence
and harm reduction. Assuming these consequences
could be measured and valued reliably, their inclusion
within the evaluative framework of a comparative
economic analysis would certainly shift the goal posts,
particularly as the key consequences in question
(e.g. property damage, violence, injuries) apply to
alcohol and opioid use but not to tobacco use.
Compared to analyses that only consider health
benefits, their inclusion would also have the effect of
enhancing the relative efficiency and policy attractive-
ness of these strategies vis-a-vis other potential areas of
health investment that do not exhibit these negative
spill-over effects. Building in part on previous develop-
ments in the area of costing the social costs of substance
abuse [1 – 3], work is under way at WHO to develop
internationally applicable guidelines and methods for
measuring and valuing these non-health consequences.
Turning to measurement issues, it is important to
note that despite the adoption of the same overarching
methodological standards, there remains room for
divergence in the analytical assumptions that can be
and are made. Two examples relating to cost measure-
ment and valuation will suffice here. First, as seen in
Table 1 and Figure 3, there are quite notable differences
in the costs of taxation policies for alcoholic versus
tobacco products. These differences, which vary in
magnitude across regions, can be accounted for by the
fact that the assumed quantity of manpower and other
resources needed to administer and enforce tobacco
taxation were calculated before the adoption of a more
generic set of WHO – CHOICE quantity assumptions
for tax enforcement (which were used for the alcohol
analysis). Secondly, and owing to the shortage of
available data from low- and middle-income countries,
opioid maintenance treatment costs are based on a
single cost estimate from a cost-effectiveness study
undertaken in Australia, subsequently extrapolated and
adjusted to the relative price levels pertaining in other
regions of the world. Such an approach evidently carries
stronger assumptions than one based on a bottom-up
analysis of quantities and their respective prices, and
may lead to an under-estimation of the actual expected
costs that would be incurred in significantly scaling-up
the availability of opiod maintenance treatment in
settings where this has yet to happen.
562 Dan Chisholm et al.
Although a sector-wide approach to cost-effectiveness
analysis sets out to provide data on a wide range of
interventions (including combination strategies), a
number of potentially applicable interventions were
not covered in this analysis because of lack of evidence.
This is especially true for illicit drugs, where not only
treatments of non-opioid substances were excluded, but
also interventions aimed at preventing drug abuse (due
in part to an inexact understanding of what components
of a combined policy response have been successful).
For example, Switzerland simultaneously witnessed a
massive expansion of methadone maintenance treat-
ment, the introduction of heroin-assisted treatment, a
massive expansion of needle exchange, the opening of
several safe injection facilities as well as changes in the
way that repression activities were conducted [46].
A final constraint of sector-wide approaches is its
emphasis on whole populations, which may be at the
expense of sub-populations that are at particular risk
(including adolescents and indigenous populations in
countries such as Australia and the United States).
There is, of course, nothing from a methodological
point of view that precludes such a focus on sub-
populations, but there remain gaps in both the
epidemiology and intervention effectiveness literature
for these selected groups.
Policy implications
The present analysis offers a novel approach to the
generation of economic evidence capable of broadly
informing substance abuse public health policy in a
wide range of epidemiological settings. Resulting
estimates of cost-effectiveness—pitched in order-of-
magnitude terms—can inform policy-makers, not only
in relation to the efficiency of existing strategies (with
respect to health outcomes), but also by identifying
priorities for substance abuse interventions in the
future. In this respect, it should be noted that in each
of the sub-regional populations considered, the most
efficient interventions for responding to the three risk
factors considered here are projected to show a
favourable ratio of cost to effect (each DALY averted
by these efficient strategies costs less than average
annual income per capita, a threshold proposed by the
Commission on Macroeconomics and Health for an
intervention to be considered very cost-effective [47]).
Furthermore, use of a common methodology enables
some comparability with cost per DALY estimates for
other risk factors or disease entities, which may
constitute an important argument in considering
priorities in the reallocation of scarce health care
resources to increase levels of population health. Of
course, if it is possible to achieve better standardisation
of cost assessment, the comparability will be further
improved.
A primary policy conclusion to be drawn from the
analysis is that, in regions with high or moderate rates of
tobacco and high-risk alcohol use, there are a number
of intervention strategies that can have a notable impact
on population health, including both individual-based
interventions such as nicotine replacement therapy or
brief physician advice as well as population-wide
measures such as taxation of alcoholic or tobacco
products. Of these, taxation has the most sizeable and
least resource-intensive impact on reducing the aver-
table burden of tobacco and high-risk alcohol use.
In regions where high-risk alcohol use represents less of
a public health burden, other intervention strategies
that restrict the supply or promotion of alcoholic
beverages appear to be promising and relatively cost-
effective mechanisms, although there is a clear need for
greater empirical support for the efficacy of these
interventions in these localities before their widespread
implementation could be considered.
Another clear conclusion from this analysis is that
governments have an important role in encouraging risk
reduction strategies for legal substances. Clearly, many
of the most cost-effective strategies are linked to
government actions; this is not only true for taxation
but also for strategies such as bans on advertisement,
random breath testing or reduction of access to legal
goods. Unfortunately, this often leads to a dilemma in
the sense that the described governmental interven-
tions, especially in the area of alcohol control, are often
unpopular and face considerable resistance from the
respective industries and their lobby groups [48]. As a
result, governments faced with considerable harm
caused by legal substances have often chosen the ‘way
of least resistance’ and implemented less cost-effective
measures such as mass-media campaigns [38,48].
In the area of illicit drug use, many of the cost-
effective government options for reducing substance-
related harm are not specifically relevant for the reason
that illegal substances cannot be controlled via mechan-
isms such as taxation or advertisement bans. That does
not mean, however, that governments should not plan
interventions in other areas such as developing the most
cost-effective repression strategies, nor does it mean
that prevention and harm reduction is impossible.
However, for future improvements there would be a
need for not only more empirical evidence on various
options (including consistent assessment of key non-
health outcomes), but also a lesser role for ideologically
motivated policy decisions.
Overall, substance abuse-related burden of disease
and social harm could be further reduced by a con-
siderable degree. This contribution tried to summarise
the knowledge on the differential cost-effectiveness of
various policy options. While the methodology was
shown as promising, its further application to addic-
tions policy is only likely to yield fruit if a wider
Comparative cost-effectiveness of policy instruments 563
evidence base for the implementation of different
interventions in less-resourced countries is established.
Disclaimer
The views expressed in this paper are those of the
authors and not necessarily those of the World Health
Organisation.
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