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            Smoking is a global problem because of the economic burden that it causes every country. According to the Framework Convention Alliance for Tobacco Control (2005), there are over 15 billion cigarettes smoked every day around the world. Its microeconomic effects to households around the world can be disastrous as it can lead to addiction that may eventually lead to hospitalization and premature death (Narayan et al, 2000). Research shows that smoking causes cancer, heart disease, stroke, and chronic obstructive pulmonary disease (World Health Organization, 1998). A previous estimation by Scollo (1996) shows that the net cost of providing extra medical services, extra hospitalization, and extra home care nursing, in Australia alone for smokers, can reach as high as $646.7 million and can increase depending on the increase of number of smokers within the country. Another example is in Canada, where nearly 7 million Canadians smoke, and an estimated 45,000 of them die every year of tobacco related diseases (Canadian Nurses Association, 2003). Its economic effect in the country is estimated that smoking-related diseases cost reach $3 billion per year in direct health care expenses (Canadian Nurses Association, 2003). The Canadian Nurses Association (2003) further added that additional cost can be added to lost productivity, increased insurance premiums and other indirect expenses, which increase the cost of tobacco use to society to $11 billion annually. In Saudi Arabia, on the other hand, it has been reported that overall prevalence of smoking was 21.1% for adult males and 0.9% for females (Jarallah et al, 1996). Furthermore, 15%-30% of Saudi adolescents smoke (Jarallah et al, 1996).


            In order to counter the negative effects of tobacco use, different smoking prevention strategies were being implemented. Several examples of anti-smoking strategies include: school based educational interventions; community interventions; mass media/public education; tobacco advertising restrictions; youth access restrictions; tobacco excise taxes; and direct restrictions on smoking (Lantz et al, 2000). However, there are also different obstacles that may bar the effectiveness of those intervention strategies, such as: nicotine addiction; social pressures; aggressive cigarette marketing and promotion; and the vested interests of those who live and profit by cigarette sales (European Commission, 2003). Furthermore, those interventions possess specific economic costs that may be a burden to the country who implements them. Three smoking prevention strategies will be explored in this assignment to compare their cost-effectiveness. Interventions to be reviewed are school-based intervention, mass media/public education and enforcement of cigarette prohibition to minor.


School-based Intervention



Wang et al (2000) explored the cost-effectiveness of a school-based tobacco-use prevention program. The data the researchers used were previously reported 2-year efficacy study of the Project toward No Tobacco Use (TNT). They measured the benefits (life years (LYs) saved, quality-adjusted life years (QALYs) saved, and medical care costs saved) and program costs (TNT's cost-effectiveness as cost per LY saved and cost per QALY saved). The summary of the results showed that in the intervention cost of $16 403, TNT prevented an estimated 34.9 students from becoming established smokers.


            In an early study, Davies et al (1984), found that the cost per current abstainer at 12 months in school-based program can range from $105 to $116 in groups with a maintenance component, compared with $126 to $135 per abstainer in groups without a maintenance component.


Tengs et al (2003), on the other hand, evaluated the cost-effectiveness of enhanced nationwide school-based anti-tobacco education relative to the status quo. The study found that over 50 years, cost-effectiveness is estimated to lie between $4,900 and $340,000 per quality-adjusted life-year (QALY) depending on the degree and longevity of program effectiveness. Furthermore, they found that assuming a 30% effectiveness that dissipates in four years, cost-effectiveness is $20,000/QALY.


            Stephens et al (2001) conducted a cost-benefit analysis to compare the costs of developing and delivering an effective school-based smoking prevention program with the savings to be expected from reducing the prevalence of smoking in the Canadian population over time. The study found that the total annual cost for a national smoking prevention program in Canada is $19.7 million. This was because of the per-pupil hourly cost of $7.29 for 1,167,000 pupils. The researchers concluded that a 6% or 4% smoking reduction can produce lifetime savings of $3,400 per person on health care and on productivity, almost $14,000. The benefit-cost ratio would be 15.4 and the net savings $619 million annually.


Media Campaign



            Pechmann and Reibling (2000) found four factors that are associated with increased cost effectiveness in smoking prevention advertising. They are: greater use of message content that prior research suggests is efficacious with youth; a more concentrated use of a single efficacious message; an avoidance of unclear messages; and an increased use of youthful spokespeople that adolescents could more readily identify with. However, in advertising, smoking prevention campaigners should be wise enough to review the rates of different types of advertisements. Advertisements can be very expensive depending on the medium being used.


            Secker-Walker et al (1997) examined the costs and cost-effectiveness ratios of a four-year mass media programme previously shown to prevent the onset of smoking among adolescents. The researchers used matched control designs with an intervention of a four-year mass media campaign to prevent the onset of smoking. They measured in the study the cost per student potentially exposed to the mass media campaign, cost per student smoker potentially averted, and cost per life-year gained. The study found that the cost of developing and broadcasting the mass media campaign was $759,436, and the cost per student potentially exposed to the campaign was $41. On the other hand, the cost per student smoker averted was $754. Then, the cost per life-year gained discounted at 3% over the life expectancy for young adult smokers was $696. The estimated cost of developing and broadcasting a similar four-year mass media campaign in all 209 American media markets would be approximately $84.5 million, at a cost of $8 per student potentially exposed to a national campaign, $162 per student smoker averted, and $138  per life-year gained.


            The effectiveness of media campaign is also being linked with the combination of other smoking prevention strategies, such as the implementation of cigarette tax on the youth. In the study of Fishman et al (2005), the cost-effectiveness of an anti-smoking media campaign and dollar 1 per pack increase in cigarette taxes on the lifetime decrease in smoking-attributable mortality among the cohort of all 18-year-olds in the United States during the year 2000 was estimated. The study found that the combined effects of a media campaign and dollar 1 per pack tax increase will result in a societal savings of between dollar 590,000 per life-year saved, at a 3% discount rate and dollar 1.4 million per life year saved, at a 7% discount rate (Fishman et al, 2005).


Enforcing Prohibition



            Another method of preventing smoking is the enforcement of cigarette prohibition to minors. However, like media campaigns and school-based programs, enforcing prohibition can also be costly. DiFranza et al (2001) calculated the cost of discounted years of life saved using reported values regarding cost and a range of assumptions regarding the impact on youth tobacco use, and found interesting results. Their study revealed that the inspection of an estimated 543,000 tobacco outlets would cost up to $190 million annually (DiFranza et al, 2001). Also, costs range from $44 to $8,200 per year of life saved depending on the discount rate and assumptions regarding cost, and efficacy (DiFranza et al, 2001). The researchers suggested that in order to compete in cost-effectiveness with implementing smoking cessation guidelines, enforcement would have to produce a 5% reduction in adolescent smoking at a cost of no more than $250 per vendor (DiFranza et al, 2001).





            In comparison, there are not many differences between the costs of the different smoking preventions strategies reviewed in this paper. However, the estimation shows that media campaigns and school-based interventions can be the most cost-effective strategies because a media campaign for four years can only cost approximately $84.5 million, while a school-based intervention program can cause only $76 million in four years. On the other hand, an implementation and enforcement of cigarette prohibition to minors may cost over a hundred dollars a year. It is too costly compared to media campaign and school-based campaigns. Nonetheless, the literature review shows that smoking prevention campaigns can be a burden to the economy of every country of the millions of dollars needed to be invested just to benefit in the long-run.




Canadian Nurses Association (2003). Tobacco: The Role of Health Professionals in Smoking Cessation Joint Statement. Canadian Nurses Association, Driveway, Ottawa ON


Davis, A.L., Faust, R., and Ordentlich, M. (1984). Self-help smoking  cessation and maintenance programs: a comparative study with 12-month follow-up by the American Lung Association. Am J Public Health 74, 1212-7.


DeFranza, J.R., Peck, R.M., Radecki, T.E. and Savageau, J.A. (2001). What is the potential cost-effectiveness of enforcing a prohibition on the sale of tobacco to minors? Prev Med, 33(3), 227


Fishman, P.A., Ebel, B.E., Garrison, M.M., Christakis, D.A., Wiehe, S.E. and Rivara, S.P. (2005). Cigarette tax increase and media campaign cost of reducing smoking-related deaths. Am J Prev Med, 29(1), 19-26


Framework Convention Alliance for Tobacco Control (2005). Tobacco Facts. Framework Convention Alliance on Tobacco Control, Genève, Switzerland

Jarallah J, Bamgboye E, Al-Ansary L, and Kalantan K. (1996). Predictors of smoking among male junior secondary school students in Riyadh, Saudi Arabia. Tobacco Control, 5,26-9.

Lantz, P.M., Jacobson, P.M., Warner, K.E. Wasserman, J., Pallock, H.A., Berson, J., and Ahlstrom, A. (2000). Investing in youth tobacco control: a review of smoking prevention and control strategies. Tobacco, Control 9, 47-63


Narayan D, Chambers R, Shah M and Petesch P. (2000). Voices of the Poor Crying Out for Change. World Bank, Washington DC,


Pechmann, C. and Reibling, E.T. (2000). Anti-smoking advertising campaigns targeting youth: case studies from USA and Canada. Tobacco Control, 9 Suppl 2, II18-31.


Scollo, M. (1996). Social Cost of Tobacco Use in Australia. Catalyst: An Information Series on Smoking and Health, Vol.18, No.3.


Secker-Walker, R.H., Worden, J.K., Holland, R.R., Flynn, B.S., and Detsky, A.S. (1997). A mass media programme to prevent smoking among adolescents: costs and cost effectiveness. Tobacco Control, 6(3), 207-12.

Stephens, T., Keiserman, M.J., McCall, D.J. and Sutherland, C. (2000). School-based Smoking Prevention: Economic Costs Versus Benefits. Health Canada, 21(2)

Tengs, T.O., Osgood, N.D., and Chen, L.L. (2003). The Cost-Effectiveness of Intensive National School-Based Anti-Tobacco Education: Results from the Tobacco Policy Model. Trandiciplinary Tobacco Use Research Center.

Wang, L.Y., and Crosset, L.S., Lowry, R. and Sussman, H. (2001). Cost-effectiveness of a School-Based Tobacco-Use Prevention Program. Arch Pediatr Adolesc Med. 155,1043-1050.

World Health organization (WHO). (1998). World no tobacco day, 31 May 1998. Geneva: WHO,


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