Reforming the delivery of smoking cessation: a distributional cost-effectiveness analysis of providing smoking cessation as part of targeted lung cancer screening

BACKGROUND: Lung cancer is a leading cause of cancer death, and smoking-related disease is a major cause of health inequality in England, driven by increased prevalence of smoking in deprived areas. Integrating smoking cessation support into the English Lung Cancer Screening (LCS) programme may optimize services and has been found cost-effective. However, limited evidence is available on its health equity impact. AIM: to estimate its impact on health inequalities and health-related social welfare in England. METHODS: The DCEA used an aggregate approach, stratifying people who smoke, aged 55-74 who were attending LCS by Index of Multiple Deprivation (IMD) quintiles. Discounted incremental costs and quality-adjusted life years (QALYs) were derived from a Markov model, adapted from previous NICE guidelines. The base case analysis applied a Health Opportunity Cost (HOC) of £15,000 per QALY and an Atkinson inequality aversion parameter (IAP) of 6.5, assuming a equal distribution across groups for intervention uptake. RESULTS: Under all base case assumptions, smoking cessation provided as part of targeted LCS had a positive net health benefit and health equity impact. The intervention dominated usual care, resulting in a total net health benefit of 142,035 QALYs. The distribution of benefit strongly favored the most deprived quintile (IMD1: 34,863 QALYs vs. IMD5: 23,612 QALYs), driven by smoking prevalence. CONCLUSION: Reforming smoking cessation services as part of LCS would likely improve both population health and health equity. Uptake of smoking cessation is a key determinant of the impact on health inequalities, underscoring the importance of targeted implementation strategies for optimizing population health, while reducing health inequalities.